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JO  L> 3 

HkM-V  . »■«»■■  — II 


ON  SYPHILIS 


AND  ITS  TREATMENT  WITH 


SUBCUTANEOUS  SUBLIMATE  INJECTIONS. 

BY 


DR.  GEORGE  LEWIN, 

PROFESSOR  AT  THE  FR.-WILH.  UNIVERSITY,  AND  SURGEON-IN-CHIEF  OF  THE  SYPHILITIC  WARDS 
AND  SKIN  DISEASES,  CHARITE  HOSPITAL,  BERLIN. 


TRANSLATED  BY 

CARL  PRGEGLER,  M.D.,  and  E.  H.  GALE,  M.D., 

SURGEONS  U.  S.  ARMY. 


WITH  ILLUSTRATIONS.  . 

ti 


1012  WALNUT  STREET. 

1882. 


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Dedicate 

TO  IIIS 

HIGHLY  ESTEEMED  COLLEAGUE 

Dr.  NICOLAUS  KOSLOFF, 

PRESIDENT  OF  THE  IMPERIAL  RUSSIAN  MEDICAL  AND  SURGICAL  ACADEMY, 
MEMBER  OF  THE  MEDICAL  COUNCIL  OF  THE  SECRETARY  OF  TUB 
t,  MEMBER  OF  SEVERAL  LEARNED  SOCIETIES, 

ETC.,  ETC.,  ETC. 

A TOKEN  OF  HIS  ESTEEM. 

*• 

$ 


I' 


TRANSLATORS’  PREFACE. 


One  of  the  translators  having  witnessed  the  success- 
ful workings  of  the  subcutaneous  use  of  sublimate  in  the 
cure  of  syphilis,  at  European  hospitals ; both  translators 
having  had  pleasing  results  in  the  number  of  cases  treated 
here  in  private  practice, — together  with  the  well-known 
standing  of  Professor  Lewin  in  all  matters  pertaining  to 
syphilitic  diseases,  they  have  been  induced  to  translate  the 
result  of  his  experiments  in  the  Venereal  Wards  of  the 
Royal  Charity  Hospital,  Berlin,  and  lay  them  before  their 
American  readers. 

We  hope  our  fellow-practitioners  will  receive  the  views 
advanced  as  to  pathology  and  treatment,  with  the  same 
spirit  as  have  some  of  the  best  surgeons  in  Europe.  And 
trust  whatever  of  value  inheres  in  his  conclusions  will  be 
tested  and  adopted. 

While  we  do  not  think  that  the  hypodermic  method  is  the 
only  way  to  eradicate  syphilis,  still,  in  many  cases,  we  think 
it  the  best,  inasmuch  as  it  is  speedy  and  sure. 

All  who  are  opposed  to  introducing  large  quantities  of 

1* 


vi  translators’  preface. 

mercury  into  the  system  cannot  fail  to  endorse  this  method, 
if  the  drug  is  to  be  used  at  all, — since  from  1J  gr.  to  2J  gr. 
of  sublimate  are  sufficient  for  a cure  on  an  average. 

The  tables  and  statistics  given  are  very  instructive ; the 
report  of  cases  is  full  and  accurate  in  details  of  treatment 
and  diagnosis ; the  deductions  seem  logical  and  conclusive. 

We  have  aimed  at  accuracy,  rather  than  elegance,  in  our 
rendering,  and  hope  the  defects  of  the  translation  will  not 
be  viewed  too  critically. 

- P.  & Gr. 


Aurora,  Illinois,  August  1,  1872. 


PREFACE. 


Nearly  seven  years  have  elapsed  since  I introduced  the 
subcutaneous  sublimate  injection  into  the  syphilitic  wards 
under  my  charge  of  the  Royal  Charity  Hospital,  Berlin. 
During  this  time  I have  treated  by  this  new  method  upwards 
of  2000  patients,  including  my  private  practice. 

The  very  favorable  success  of  the  method  may  justify  me 
in  responding  to  the  numerous  wishes  of  my  colleagues  here 
and  elsewhere.  And  I present  here  to  the  reader  my  work 
laid  down  in  the  14th  volume  of  the  Charity  Annals,  con- 
densed and  improved. 

I remarked  there  the  advantages  of  my  treatment,  espe- 
cially the  qmckness  and  precision  of  the  results,  the  small 
amount  of  relapses,  &c.,  and  more  than  all  those  theoretical 
arguments ; I give  here  the  following  statistical  data,  which 
speak  for  themselves. 

In  Berlin  the  law  exists  that  every  woman  given  to  pros- 
titution may  be  under  police  surveillance , and  those  who 
lead  a suspicious  life  have  to  be  examined  weekly,  and  any 
exploration  giving  a warrantable  proof  of  syphilis,  gives  the 
examining  surgeon  the  right  to  send  them  to  my  syphilitic 


VJ11 


PREFACE. 


wards.  I have  treated  all  these  women  exclusively,  since 
March,  1865,  by  my  new  method,  and  their  number  already 
is  about  1400. 

At  the  end  of  July,  1869,  there  had  not  been  more  than 
20  female  patients  who  had  returned  to  my  wards  on  account 
of  syphilitic  relapses , which  were  of  a very  light  character, 
as  the  following  cases  will  show. 

But  I am  far  from  thinking,  notwithstanding  its  remark- 
able results,  that  the  injection  method  is  the  only  cure  to  be 
adopted,  and  I earnestly  protest  against  such  a onesidedness 
on  my  part. 

I express  my  profound  obligation  to  all  my  colleagues, 
who,  unbiased  and  with  a scientific  zeal,  have  tried  my  new 
method ; especially  would  I name  Regimental  Surgeon  Der- 
blich;  Dr.  Gruenfeld,  assistant  to  Professor  Siegmund,  at 
Vienna;  Professor  Bamberger,  Wuerzburg;  Dr.  Bergson, 
Professor  in  our  University,  and  Dr.  C.  W.  Richter. 


Lewin. 


CONTENTS 


I.  Definition 

II.  The  Manner 

1.  Instruments 

2.  Place  for  injection  ...... 

3.  Medicated  fluid  for  injection 

4.  Doses 

III.  On  the  Appearances  occurring  after  Injection 

1.  Local  appearance  . . . 

a.  Inflammation 

b.  Formation  of  abscesses  .... 

c.  Injury  to  vessels 

d.  Jnterruption  of  sensibility 

2.  General  symptoms 

a.  Disturbances  of  digestion  . . • . 

b.  Disturbances  of  respiration  and  circulation  . 

c.  Disturbances  of  the  urinary  organs  . 

d.  Disturbances  in  the  functions  of  the  skin  and 

hair  ....... 

e.  Disturbances  in  the  osseous  system 

/.  Disturbances  in  the  formation  of  blood 
g , Disturbances  of  the  nervous  system 
Symptoms  of  intoxication  . . 

IV.  Dietetic  Rules 

a.  Concerning  the  body 

b.  Psychical  considerations 

Y.  Indication  for  Injection 

1.  Initial  syphilis  . . . . . 

2.  Condylomata  lata 

a.  In  women 

1.  Seat  of  condylomata  lata  . 

b.  In  men  . 

c.  Therapeutics  of  syphilitic  sclerosis  and  broad 

condylomata  lata  .... 


PAGE 

13 

13 

13 

15 

IT 

19 

20 

20 

20 

21 

22 

23 

25 

25 

32 

32 

32 

33 

33 

35 

37 

39 

39 

42 

43 

44 

47 

51 

54 

54 

56 


X 


CONTENTS. 


PAGE 

3.  Swelling  of  the  lymphatic  glands  ...  63 

4.  Affection  of  the  mouth  and  pharynx  ...  66 

Cavum  pharyngo-orale  . . . . . 67 

Region  of  the  sebaceous  glands  . . . 68 

Region  of  the  acinous  glands  ...  69 

Cases  1 and  2 70,  71 

Plaques  opalines 72 

Condylomatous  granulations  ...  73 

Foveae  tonsillaris 73 

♦ Cavum  pharyngo-nasale  ....  75 

Choanse,  tuba  eustachii,  tonsilla  pharyngea  75 

Case  3 76 


Condylomatous  and  papillary 
on  the  palate 

Cases  4-8  . . . . 

Deep  ulcerations  and  defects  in 
Cases  9-18  .... 

Infectio  per  os 

Cases  19-27  .... 

• Infection  of  nurse  and  child 

5.  Syphilitic  affections  of  the  larynx 

Syphilitic  catarrh  of  the  larynx 
Differential  diagnosis 
Submucous  infiltration 
Prolific  granulations 
Ulcerations 
Gummous  processes 
Differential  diagnosis 
Therapeutics  . 

Cases  28-40 

6.  Syphilitic  affection  of  the  skin 

Maculous  exanthem  . 

Exanthema  coeruleum 
Papulous  exanthem  . 

Miliary  and  lenticular  species 
Cases  41-43 
Squamous  exanthem 
Cases  44-45 

Condylomatous  exanthem 


the 


granulations 

. 78 

. 79-82 

pharynx  86 
. 88-95 

. 9£> 

. 98-101 
. 103 

104 
. 104 

105 
. 106 

107 
. Ill 
1 14 
. 115 

116 
118-130 
131 
. 131 

134 
. 135 

136 
137-139 
140 
142,  143 
144 


CONTENTS. 


XI 


PAGE 


Cases  46  and  47 

. 146 

Ulcerous  exanthema  and  rupia  syphilitica 

147 

Cases  48-50  

148-150 

Knotty  syphiloid  ..... 

151 

Lupus  syphiliticus  ..... 

. 152 

Cases  51  and  52 

155-157 

Gummata  of  the  subcutaneous  cellular  tissue  . 159 

Cases  53  and  54  .... 

161-163 

7.  Syphilitic  affection  of  the  eye  .... 

. 164 

Cases  55-60  

167-171 

8.  Syphilitic  tumors  of  the  scrotum 

. 171 

Case  61 

173 

9.  Syphilitic  diseases  of  the  bone 

. 175 

Therapeutics- 

176 

Cases  62-64  

177-179 

10.  Visceral-syphilis  

180 

A.  Syphilitic  diseases  of  the  liver 

. 181 

Perihepatitis  .... 

181 

Cirrhosis  ..... 

. 182 

Icterus  .... 

182 

Cases  65  and  66 

184,  185 

B.  Syphilitic  diseases  of  the  kidney 

186 

Cases  67  and  68  ... 

188-190 

C.  Syphilitic  affection  of  the  brain 

191 

Apoplexy,  epilepsy,  hemiplegia 

. 191 

Psychosis 

191 

Cases  69-71 

196-199 

VI. 

Considerations  with  Sublimate  Injections  . 

202 

Age.  Sex.  Menstruation.  Acute  diseases 

202-203 

Dyscrasia 

203 

Cases  72  and  73 

204-205 

VII. 

Quantity  of  Sublimate  to  be  Injected 

206 

Statistics  of  800  patients  ..... 

. 207 

Results  . . . * 

209 

nil. 

Relapse  of  Syphilis 

. 210 

Devergie  ........ 

211 

Desruelles 

Fergusson 

212 

Thom.  Clarke  . . . ... 

. 212 

Xll 


CONTENTS. 


PAGE 

Royal  Swedish  Sanitary  Commission  . . . 213 

Calderini • . . . 213 

Hermann  . 213 

Diday 214 

Yvaren 214 

Engelsted 215 

Boeck 215 

Auzias  Turenne 216 

A.  Oewre 217 

Depres 217 

Statistics  taken  from  the  Charite  Journals  concerning 
the  prevalence  of  relapses  after  sweat  and  mercury 

cure 217 

Quality  of  the  relapses  . 222 

u 11  11  with  botanic  treatment  . 224 

“ 11  11  li  mercury  treatment  . . 225 

11  <l  11  u subcutaneous  treatment  225 
Cases  of  progressive  relapses  with  subcutaneous  injec- 
tions   227 

Doses  of  sublimate  in  relapses  ....  230 

Intervals  between  the  single  relapses  ....  232 

A.  Sarsaparilla  sweat-cure  ....  232 

B.  Mercury  cure . 234 

C.  Subcutaneous  sublimate  injection  cure  . 236 

Tabulated  review  of  prevalence  of  relapses  in  one  and 

the  same  patient  .......  239 

Review  of  intervals  with  relapses  occurring  more  than 

once 240 

IX.  Effect  of  the  Subcutaneous  Treatment  on  Pregnant 

Females 241 

Review  of  the  pregnant  women  treated  subcutaneously  242 
Influence  on  the  foetus 243 


THE 


TREATMENT  OF  SYPHILIS 

WITH 

SUBCUTANEOUS  SUBLIMATE  INJECTION. 


I.  DEFINITION. 

By  the  new  method,  introduced  by  me,  Syphilis  may  be 
destroyed,  in  its  various  forms,  when  the  remedy  is  brought 
in  contact  with  the  system  in  the  form  of  hypodermic  in- 
jections of  corrosive  sublimate.  This  method  has  the  ad- 
vantage over  other  anti-syphilitic  cures,  inasmuch  as  it 
requires  no  preparation  of  the  system  for,  nor  any  after- 
cure in  consequence  of,  the  medicine  taken,  because  we  can 
proceed  at  once  in  medias  res , without  losing  any  time 
whatever. 

II.  THE  MANNER. 

I.  INSTRUMENT. 

The  instrument  used  is  a syringe,  modified  by  Dr.  Lewin 
and  manufactured  by  Geo.  Tiemann  & Co.,*  New  York.  It 

* They  have  constructed,  by  our  request,  a hypodermic  syringe,  ac- 
cording to  Lewin’s  modification,  and  we  recommend  the  instrument  to 
the  profession,  as  an  improvement  upon  the  one  in  common  use. — 
Translator’s  Rem. 

2 


14 


THE  MANNER. 


is  essential  to  have  this  modified  instrument,  a drawing  of 
which  accompanies  this  book.  In  private  practice  each  pa- 


tient ought  to  have  his  own  “needle,”  which  must  fit  the 
syringe  used  by  the  practitioner,  so  that  no  possible  chance 
of  infection  may  exist.  It  is  always  a duty  before  using  the 
syringe  to  be  sure  it  is  in  working  order,  because  it  is  a 
needless  torture  for  the  patient,  if  you  insert  a clogged  and 
unclean  instrument.  Great  precaution  and  circumspection 
are  necessary  on  the  part  of  the  physician.  To  preserve 
the  good  condition  of  the  syringe,  it  is  best  to  use  distilled 
water  for  cleansing  it ; care  being  taken  that  no  fluid  remain 
in  the  glass  tube,  which  may  be  effected  by  repeated  work- 
ings of  the  piston. 

The  needle  should  be  dried,  blowing  every  particle  of 
water  out  of  it ; use  watch-makers’  oil  to  keep  it  from  rust- 
ing, Inserting  a bristle  instead  of  gold  or  silver  wire. 

The  operation  itself  is  the  same  as  with  any  other  subcu- 
taneous injection.  The  cuticle  ought  to  be  raised,  and  the 
point  of  the  syringe  pushed  into  the  middle  of  the  cellular 
tissue,  thus  elevated.  Be  careful  and  not  penetrate  so  deeply 
as  to  injure  the  muscle,  neither  go  too  superficially,  because 
the  medicated  fluid  remaining  in  the  tense  and  unyielding 
stratum  of  cuticle,  will  not  be  absorbed,  but  give  rise  to 
inflammation  and  sloughing  of  the  part ; therefore  it  is  of 


PLACE  FOR  INJECTION. 


15 


vital  importance  that  the  medicated  fluid  be  deposited  in  the 
meshes  of  the  cellular  tissue.  I saw  quite  a good  many 
sick,  brought  to  the  Charity  Hospital,  who  were  covered  on 
their  backs  and  chests  with  deep-seated  abscesses,  complain- 
ing of  much  pain,  without  my  being  able  to  detect  any  effect 
brought  about  by  the  injection  of  the  sublimate  ; on  the  con- 
trary, seeing  plainly  that  the  syphilitic  taint  was  in  full 
bloom.  Such  cases,  brought  about  through  ignorance,  may 
give  rise  to  misunderstandings  and  distrust  against  the  effi- 
cacy of  the  injection. 

In  persons  with  a good  deal  of  fatty  tissue  ( panniculus 
adiposus ),  the  skin  sometimes  cannot  be  raised  in  a fold,  but, 
without  trying  repeatedly,  the  “ needle”  of  the  syringe  may 
be  boldly  inserted  from  half  an  inch  to  an  inch,  according 
to  the  adipose  tissue.  I never  noticed  in  such  subjects, 
abscesses.  Generally  speaking,  there  seems  to  be  less  sus- 
ceptibility to  inflammation. 

In  drawing  the  needle  out,  put  your  finger  immediately 
over  the  aperture  and  compress  it,  and  by  gentle  rubbing, 
the  injected  fluid  will  be  equally  distributed  in  the  tissue. 
This  is  indispensable  for  preventing  any  loss  of  the  fluid, 

the  smallness  of 
be  any  bleeding, 
it  will  be  proper  to  close  the  opening  with  adhesive  plaster, 
but  generally  digital  compression  will  suffice. 

II.  PLACE  FOR  INJECTION.* 

Generally  speaking,  we  find  on  all  places  of  the  body,  the 
same  readiness  of  absorption,  since  salivation  occurs  readily 

* By  examining  the  cut  accompanying  this  work,  there  may  be  seen 
the  regions  best  adapted  for  inserting  the  injections. 


because  such  a loss  is  of  importance,  taking 
the  injection  into  account.  If  there  should 


16 


THE  MANNER. 


from  almost  any  place.  Since  I fail  to  find  any  difference 
as  to  locality,  I seek  parts  that  are  the  least  sensitive,  and 
am  guided  solely  by  this  consideration.  The  less  sensitive 
a place  of  the  body  is,  when  the  tissues  are  punctured,  the 
less  will  the  part  inflame,  and  hence  the  better  suited  for 
our  purpose.  This  condition  prevails  in  the  infrascapular 
and  sacral  regions.  I have  allowed  my  patients  to  desig- 
nate, themselves,  the  special  point  in  these  regions.  Most 
of  them  selected  the  infrascapular,  it  being  not  so  sensitive, 
and  the  muscles  coming  but  little  into  play  while  moving 
the  body.  Here  the  nerve  inosculations  are  more  sparsely 
disseminated.  Should  these  spaces  be  insufficient  on  ac- 
count of  the  repeated  injections,  the  adjoining  regions,  or 
even  the  chest  has  to  be  taken.  There  is  no  danger  of  ab- 
scesses here,  but  patients  complain  of  pains  darting  into 
the  upper  extremities,  and  even  numbness,  which  passes  off 
in  a few  hours. 

The  sacral  region  is  not  very  sensitive,  but  the  skin  is 
sometimes  so  adherent  that  a fold  is  hardly  to  be  raised. 
Better  is  the  region  of  the  gluteii  muscles , and  especially  for 
such  persons  as  are  used  to  horseback-riding,  because  of  the 
hardness  of  the  parts.  But  the  needle  needs  to  be  inserted 
rather  deeper  here,  and  compression  ought  to  be  made 
longer  at  the  aperture,  because  the  fluid  escapes  more  easily 
than  at  other  points. 

With  most  patients,  the  infrascapular  region  was  best 
adapted  to  our  purpose.  The  pain  was  seldom  much  greater 
than  in  other  places  mentioned  above,  and  I have  not  seen 
any  abscesses  arise  here.  They  have  occurred  in  other 
regions,  as  on  the  anterior  part  of  the  forearm,  which  is 
usually  not  very  sensitive.  With  severe  cases,  which  have 
to  lie  in  bed,  the  lower  extremities  may  be  used,  and  ought 


MEDICATED  FLUID  FOR  INJECTION* 


17 


to  be  preferred  instead  of  the  back,  on  account  of  the  decu- 
bitus of  the  patient. 

We  should  avoid  those  regions  where  there  is  a collection 
of  glands , because  tedious  and  chronic  abscesses  may  follow, 
as  the  regio  cervicalis , submaxillar  is , inguinalis , cubitalis. 

Whether  an  already  injected  place  ought  to  be  again  used, 
depends  largely  whether  or  not  infiltrations  or  indurations 
have  been  formed.  With  some  patients  infiltrations,  after 
use  of  the  syringe,  occur  but  slightly,  and  quickly  disap- 
pear ; with  others,  they  stay  for  a longer  time,  and  are,  on 
that  account,  a contra  indication. 

It  is  interesting  that  such  infiltrations  seem  to  compress 
the  sensitive  nerves  even  to  anaesthesia,  a reinsertion  of  the 
needle  causing  no  pain.  On  this  account  patients  have  a 
predilection  for  such  parts  where,  if  reapplied,  sometimes 
ulceration  of  the  tissue  may  be  induced. 


MEDICATED  FLUID  FOR  INJECTION. 

I use  for  injections  these  three  solutions  of  different 
strength : 

1.  3 grains  to  one  ounce  of  water. 

2.  4 a a u a 


More  concentrated  solutions  than  No.  3 cause  often  intense 
local  inflammation  and  sensitiveness,  and  abscesses  form. 
Weaker  solutions  than  No.  1 have  too  little  effect,  and  have 
to  be  repeated  too  often.  Which  of  the  solutions  to  use  in 
any  single  case,  must  be  determined  by  idiosyncrasy  of  the 
patient,  sensitiveness,  susceptibility,  &e.  Generally,  I pre- 
fer in  practice  the  middle  strong  solution,  and  wTith  patients 
in  Cliarite  Hospital,  I use  it  mostly. 


18 


THE  MANNER. 


In  private  practice,  considering  many  circumstances,  I 
prefer  to  begin  with  the  weakest  solution,  getting  gradually 
to  the  stronger  one,  especially  in  patients  who  are  very  sus- 
ceptible to  pain  and  in  a rather  weakly  condition.  In  pa- 
tients where  symptoms  of  weakness  are  predominant,  it  is 
necessary  to  find  out  whether  the  debility  is  a product  of  the 
syphilis,  or  is  induced  by  weakening  causes,  such  as  insuffi- 
ciency of  food,  exhaustive  discharges,  &c.  Should  it  be 
advisable  to  purge  a healthy,  robust  individual,  it  is  best  to 
begin  with  the  weakest  solution,  continuing  it  till  at  least 
the  more  concentrated  ones  can  be  applied.  But  I use  the 
concentrated  solution  in  those  patients  mentioned  above 
(patients  who  have  been  reduced  by  syphilis),  even  if  their 
state  of  strength  might  be  considered  by  a novice  a counter- 
indication for  every  mercurial  cure.  In  such  cases  the 
injection  of  sublimate  shows  triumphant  results,  even  if  the 
pain  induced  by  the  concentrated  solution  is  quite  severe, 
and  wears  on  the  patient.  It  will  be  of  but  short  duration, 
and  the  patient  who  has  hitherto  been  pale  and  worried, 
gets  a better  color  and  a better  skin,  noticeable  even  to  a 
non-professional  eye.  He  himself  assures  you  he  feels 
quite  improved. 

I use  the  stronger  solutions  in  those  cases  wh^e  the  skin 
tolerates  it  and  other  indications  demand  a heroic  treatment-. 
Those  indications  are  given  either  by  the  dignity  of  the 
organ  which  is  syphilitically  affected  (and  I mean  here  espe- 
cially the  brain,  the  larynx,  the  eye),  or  by  a threatening, 
intense  course  of  syphilis,  such  as  the  phagedenic  condition 
of  an  ulcerating,  broken-down  venereal  sclerosis.  Those 
affections  which  have  existed  in  long  and  neglected  syphilis, 
especially  gummy  tumor  of  the  scrotum,  tophi  of  the  bones, 
&c.,  require  tli  e concentrated  solution.  The  curative  pro- 


DOSES. 


19 


cess  commences  very  soon  with  them.  We  may  use  the 
stronger  solutions  in  cases  of  slight  syphilis,  if  the  patient  is 
willing  and  can  endure  the  pain,  or  if  urgent  social  reasons 
are  predominant. 

To  mitigate  the  pain  attending  any  of  the  named  solu- 
tions, morphia,  with  or  without  glycerin,  may  be  added. 
The  amount  to  be  given  varies  from  y1^  grain  to  £ grain, 
judging  by  the  symptoms,  if  larger  doses  are  demanded. 
And  I may  mention  here  that  in  some  cases  a combination 
of  morphia  and  the  sublimate  had  a narcotic  influence,  fol- 
lowing more  quickly  than  in  ordinary  cases.  • In  some  cases 
it  was  the  reverse*  Every  one  who  has  experimented  knows 
the  difficulty  in  obtaining  exact  and  uniform  results. 

DOSES. 

Concerning  the  partial  doses  for  every  administration  of 
the  injection  fluid,  the  smallest  dose  is  y1^  gr.  sublimate  and 
the  highest  g gr.  These  minimum  and  maximum  doses  I 
but  seldom  overstep,  and  the  same  are  sufficient  for  most 
cases  for  one  and  the  same  day.  In  several  exceptional 
cases  I have  used,  experimentally,  § gr.,  and  even  a grain 
per  day ; but  we  must,  in  these  instances,  be  on  the  alert  for 
appearances  of  intoxication,  which  I shall  more  fully  de- 
scribe by  and  by. 

Which  of  the  two  doses  ought  to  be  used,  depends  on  two 
circumstances  : first,  on  the  individuality  of  the  patient ; and 
second,  on  the  gravity  of  the  case. 

Concerning  individuality,  with  weakly  subjects,  we  begin 
with  the  weaker,  and  with  healthy  ones,  with  the  stronger 
dose.  In  the  course  of  the  treatment,  a good  deal  depends 
on  the  sooner  or  later  commencement  of  the  mercurial 


20  APPEARANCES  OCCURRING  AFTER  INJECTIONS. 


stomatitis,  or  the  susceptibility  of  the  patient ; and  by  this 
we  may  know  whether  to  increase  the  dose  or  not.  In  all 
cases  where  lues  threatens  important  organs,  higher  doses 
are  imperatively  indicated,  as  already  said.  In  most  cases 
I do  not  inject  more  than  the  contents  of  a Pravaz  syringe 
in  one  place  (the  same  as  a half  of  my  own,  viz. : 15  grains). 
But  if  I wish  to  use  more,  I inject  in  two  places  somewhat 
distant  from  each  other . Very  often  I take  opposite  parts 
of  the  body.  By  this  means  greater  doses  may  be  injected 
at  once ; but  if  circumstances  allow  it,  they  ought  to  be 
divided  into  two  or  three  sections  of  the  day,  at  intervals  of 
three  or  four  hours." 


III.  ON  THE  APPEARANCES  OCCURRING  AFTER 
INJECTIONS. 

I.  LOCAL  APPEARANCE. 

a.  Inflammation. — The  injection  of  the  sublimate  is  soon 
followed  by  more  or  less  redness,  diffused  around  the  open- 
ing, accompanied  by  a swelling,  which  seems  to  arise  chiefly 
from  the  depth  of  the  subcutaneous  tissue,  where  the  subli- 
mate has  been  deposited.  A more  or  less  tense  infiltration 
forms,  which  slightly  elevates  the  non-affected  surface  above 
the  level  of  the  surrounding.  While  the  traumatic,  su- 
perficial erythema  disappears  quickly,  the  induration  re- 
mains a longer  time.  With  some  patients  spontaneous 
involution  follows ; with  others,  knotty  hardness  remains 
for  quite  a while.  The  cause  of  these  differences  lies  in  the 
individual  idiosyncrasies  which  generally  characterize  the 
ability  to  withstand  traumatic  influences.  But,  in  time,  the 
most  obstinate  knot  will  disappear,  as  I have  seen  with  all 


LOCAL  APPEARANCE. 


21 


patients  discharged  with  some  swelling,  and  who  returned  to 
the  Hospital  afterwards  without  haying  a trace  left. 

b.  Formation  of  Abscesses . — Concerning  the  most  dreaded 
determination  of  the  disordered  inflammation  in  suppuration 
and  abscesses , I am  able  to  quiet  all  apprehensions.  From 
one  thousand  patients  of  my  private  practice  only  one  had  a 
small  abscess  on  the  forearm.  More  frequently  they  oc- 
curred in  the  Charity  Hospital,  on  account  of  newly-arrived 
assistant  surgeons,  &c.  Soon,  however,  they  acquire  dex- 
terity, and  abscesses  are  rare,  hardly  ever  occurring  with 
ordinary  precautions. 

As  I have  said  before,  each  local  inflammation  may  be 
produced  by  either  the  quality  or  quantity  of  the  sublimate 
solution.  As  small  doses  of  very  concentrated  solutions,  by 
their  more  intense  chemical  action  on  the  tissues,  produce, 
easily  enough,  local  inflammation  tending  to  abscesses,  so 
great  quantities  of  a very  weak  solution  will  give  rise  to 
mechanical  tearing  and  loosening  of  the  tissues,  with  the 
same  result.  The  regions  which  are  especially  predisposed 
for  abscess  formations,  seem  to  be  the  same  which,  with  the 
so-called  syphilitic  inclination,  go  over  into  profuse  suppu- 
ration. These  regions  show  the  same  disposition  with  sub- 
limate injections. 

In  the  beginning  of  my  experiments,  viz.:  the  experi- 
mental stadium  of  my  practice,  I generally  took  those 
regions  for  injections  which  were  situated  in  the  neighbor- 
hood of  large  lymphatic  glands,  and  I then  imagined  the 
deposits  of  the  “ materia  pecans/’  occasioned  frequent 
deep-seated  abscesses. 

The  subcutaneous  cellular  abscesses  take  a different  course, 
according  to  not  only  either  the  greater  or  smaller  quantity, 
or  stronger  or  weaker  solution,  but  also  according  whether 


22  APPEARANCES  OCCURRING  AFTER  INJECTIONS. 


injected  superficially,  or  more  deeply  into  the  cellular 
tissue.  Suppuration  generally  takes  place  when  the  fluids 
are  deposited  in  the  stratum  of  cuticle,  because,  absorbing 
vessels  being  wanting,  the  elastic  fibres  undergo  a protracted 
stretching,  and  finally  tear. 

With  injections  of  a too  concentrated  character,  or  with 
too  great  a quantity  of  weaker  solutions  in  the  subcutaneous 
cellular  tissue,  especially  in  the  regions  of  large  glands,  the 
swelling  (exsudat — Ger.  Nosol.)  commences  immediately ; 
but  only  after  some  time  does  it  soften  into  an  abscess.  I 
have  not  yet  discovered  a dangerous  termination  of  an  ab- 
scess, nor  erysipelatous,  or  lymphangoid  inflammation. 

c.  Injury  to  Vessels . — Bleedings  from  pierced  veins  were 
not  very  seldom  with  injections,  but  never  was  it  of  such 
magnitude  (depending  on  the  locality  of  the  injured  vein)  as 
to  have  caused  trouble.  Bleeding  cannot  be  avoided,  even  if 
places  of  varicose  veins,  ncevi  telangiectasia , &c.,  are  not 
touched.  Digital  compression  is  quite  sufficient,  and  never 
did  I have  to  resort  to  ligation  or  Liquor  Ferri,  Sesqui 
Chloridi,  Argentum  Nitricum,  &c.  But  as  cases  occur 
where,  a little  after  the  administration , venous  hemorrhage 
begins,  and  the  patient  may  be  surprised  after  the  physician 
is  gone,  it  is  best  to  avoid  it  by  compression  of  the  opening 
for  a few  minutes,  as  it  will  prevent  after  bleeding.  You 
may  instruct  the  patient  himself  to  compress  it  after  you 
have  left.  If,  however,  a little  bleeding  occurs,  it  is  rather 
beneficial  than  injurious  ; and  so  it  is  well  to  briefly  delay 
compression,  since  it  may  prevent  stagnation  of  blood, 
which  is  apt  to  be  painful. 

There  are  some  published  cases  where,  by  the  opening  of 
a vein  with  a hypodermic  morphine  injection,  rapid  intoxica- 
tion commenced,  as  if  the  medicated  fluid  passed  directly  into 


LOCAL  APPEARANCE. 


23 


the  circulation  of  the  blood.  Nussbaum  was  first  to  report  it, 
and  after  him  Spencer  Wells  and  Feith  (Cologne).  In  those 
cases  rapid  intoxication,  immediately  after  a small  loss  of 
venous  blood,  ensued.  I had  two  similar  cases.  Both  were 
young,  healthy  men,  of  whom  the  one,  right  after  the  injec- 
tion, sank  down  with  pallor  and  vertigo.  The  other  com- 
plained shortly  after  of  dizziness,  soon  losing  his  conscious- 
ness for  a few  moments.  Without  trying  to  explain  these 
phenomena,  I doubt  very  much  the  view  taken  by  several 
professional  gentlemen,  that  a thrombus  was  formed. 

The  rapid  narcotism  seems  to  be  due  to  quickened  ab- 
sorption, and  perhaps  to  the  regions  where  injected.  In  the 
cases  mentioned  by  me,  I neither  increased  the  usual  dose 
nor  administered  in  any  other  place  than  the  regions  desig- 
nated above.  The  mentioned  cases  had  no  resemblance  to 
the  common  ones  of  mercury  poisoning.  One  of  my  pa- 
tients, in  whom  toxic  appearances  were  manifest,  told  me 
afterwards  that  he  “ could  not  see  blood,”  and  it  maybe 
possible  to  attribute  it  to  that.  Further,  as  the  related 
cases  did  not  end  badly,  they  cannot,  therefore,  be  paraded 
to  the  discredit  of  the  method . 

It  has  been  said  that  by  drawing  back  the  piston,  the 
inj^ed  fluid  might  be  pumped  out,  but  I fail  to  understand 
it,  and  I cannot  sustain  Nussbaum’s  view,  “to  inject  very 
slow,  so  as  to  avoid  these  occurrences/ ’ 

d.  Interruption  of  Sensibility. — Through  the  piercing  of 
the  needle  into  the  skin,  together  with  the  action  of  the 
always  somewhat  acrid  solution,  pain  will  be  brought  about. 
The  mechanical  momentum , produced  by  piercing,  does  not 
differ  from  the  pain  induced  by  any  other  subcutaneous 
medication ; and,  as  I said  previously,  the  pain  can  be  con- 


24  APPEARANCES  OCCURRING  AFTER  INJECTIONS. 


siderably  lessened  by  the  dexterity  of  the  operator,  and  the 
good  condition  of  needle  and  syringe. 

Some  patients  ar6  highly  sensitive — as  I have  had  occasion 
to  observe,  on  the  person  of  a healthy,  robust  military  offi- 
cer, who  swooned  away  with  every  piercing  of  the  needle. 
To  counteract  this,  it  might  avail  to  use  a liniment  of  chlo- 
roform or  ether,  according  to  the  suggestion  of  my  esteemed 
colleague,  Dr.  Bergson. 

The  sensitive  symptoms,  produced  by  the  injected  subli- 
mate solution , are  of  greater  importance,  especially  through 
the  corroding  injluence  on  the  nerves  of  the  subcutaneous 
tissue.  They  may  follow  immediately  after  administration, 
and  quickly  disappear,  or  continue,  and  after  an  hour  or  so 
reach  their  climax.  The  sensitiveness  of  patients  varies. 
Some  hardly  feel  the  pain ; some  describe  it  as  very  violent, 
and  even  cases  have  occurred  where  patients  were  refrac- 
tory. The  wound  remains  for  quite  a time  sensitive  to  the 
touch,  and  so  highly  disagreeable  to  the  patient  is  it,  that  he 
cannot  lie  down  on  his  side,  as  usual ; thus  being  disturbed 
in  his  rest.  It  is  best  not  to  make  piercings  on  the  side 
upon  which  the  patient  is  accustomed  to  lie,  and  not  too 
near  bed-time.  But  if,  with  all  these  precautions,  the  pa- 
tient passes  a sleepless  night,  morphine  is  not  contraindi- 
cated. In  the  course  of  the  treatment,  patients  get  used  to 
the  described  pains.  A circumstance  not  ordinarily  desira- 
ble, the  formation  of  a hard  infiltration,  as  a consequence  of 
the  injection,  seems  to  blunt  the  nervous  sensibility.  Per- 
sons who  feel  no  pain  when  the  skin  is  pierced,  nor  any 
discomfort  from  the  injected  fluid,  require  for  a permanent 
cure  a greater  amount  of  injection.  There  are  exceptional 
cases,  where  the  sensitiveness  increases  the  longer  the  treat- 
ment continues. 


GENERAL  SYMPTOMS. 


25 


To  find  an  infallible  remedy  for  this  hyperaesthesia  would 
be  an  advantage  for  the  method  and  overcome  this  objection. 
In  general,  a combination  of  morphia  with  the  sublimate  has 
acted  well  in  my  hands.  In  some  cases  a cold  compress  was 
sufficiently  soothing ; in  others,  chloroform  liniment  had  the 
desired  effect.  And,  as  previously  mentioned,  it  is  best,  in 
these  sensitive  cases,  to  begin  with  the  weaker  solutions, 
gradually  rising  to  the  stronger.  If  the  hyperaesthesia  be- 
comes excessive,  it  is  advisable  to  suspend  for  a few  days. 

II.  GENERAL  SYMPTOMS. 

In  thus  using  mercury  hypodermically,  the  question 
arises,  to  what  extent,  and  in  what  way,  will  the  knowTn 
symptoms  of  hy  dr  argyrosis  exist  ? 

Without  going  into  the  discussion  of  the  preliminary 
questions,  whether  the  dreaded  symptoms  have  their  origin 
in  this  metal,  or  are  a combination  of  syphilis  with  mercu- 
rialism,  or  whether  they  are  nothing  more  than  derivations 
of  syphilis,  and  wrongly  imputed  to  mercury,  I must  openly 
confess  that  I hold  the  latter  view,  and  will  only  point  to 
the  fact  that,  after  the  hypodermic  use  of  the  sublimate  in 
patients  with  lues , I have  had  occasion  to  observe  but  few  of 
the  so-called  symptoms.  The  injury  from  the  mercury  was 
but  slight,  and  can  be  prevented  for  the  most  part.  If  we 
consider  more  minutely  the  effect  of  subcutaneously  injected 
sublimate  on  the  different  organs,  we  see : 

a . Disturbances  of  Digestion . — Concerning  the  digestive 
organs , upon  which  mercury  by  the  mouth  acts  so  delete- 
riously,  I have  to  say,  I could  not  detect  anything  injurious 
resulting  from  the  subcutaneous  method.  The  smallness  of 
the  dose  was  the  self-evident  reason.  Whenever  disturb- 


3 


26  APPEARANCES  OCCURRING  AFTER  INJECTIONS. 


ances  of  the  digestive  apparatus  arose,  which  was  quite 
seldom,  the  effect  of  the  medicine  was  generally  not  the 
cause,  but  other  affections,  as  catarrh  of  the  mucous  mem- 
brane of  the  stomach  and  intestines — an  affection  standing 
in  close  connection  to  indigestion.  Neither  did  I perceive 
deleterious  effects  on  other  organs,  as  the  liver , pancreas , 
spleen — a fact  in  decided  contradiction  with  Graves,  Dieter- 
ich,  Rokitansky  and  Lorinser,  who  especially  record  dis- 
turbances of  manifold  character  in  these  organs,  after  use 
of  mercury  by  the  mouth. 

In  many  cases  where  the  undesirable  complication  of  icte- 
rus was  present  (which  we  shall  dwell  on  more  fully  here- 
after), we  have  seen  it,  together  with  the  syphilitic  affection, 
disappear  with  the  subcutaneous  injections.  I never  have 
seen  a symptom  in  any  case  which  could  be  traced  to  mer- 
curial hepatitis , adenophyma  or  adiposis  hepatica . Con- 
cerning the  effect  of  sublimate  on  the  mucous  membrane  of 
the  mouth,  it  seems  as  if  mercury  in  any  aggregated  state 
induces  ptyalism . Only  recently,  Kirchgaesser,  in  Virchow’s 
“ Archive,”  tried  to  point  out  that  mercurial  vapors  also  are 
in  close  connection  with  producing  ptyalism.  That  mercury, 
given  in  powders  and  assimilated  by  the  stomach  in  the  solid 
aggregate  state,  induces  salivation,  is  well  known.  And 
even  the  sublimate , subcutaneously  injected,  gives  rise  to  the 
same  process,  and  often  very  quickly.  I have  often  ob- 
served that  after  a few  hours  only,  symptoms  of  salivation 
would  show  themselves. 

Generally,  we  may  classify  the  affections  of  the  mouth, 
resulting  from  sublimate  injections,  in  three  categories: 

1.  The  first  form  consists  of  a slightly  inflamed  condition 
of  the  mouth , generally  resembling  simple  stomatitis,  ushered 
in  by  gentle  swelling  of  the  submaxillary  glands,  sensitive 


GENERAL  SYMPTOMS. 


27 


to  the  touch  and  somewhat  painful.  The  mercurial  stoma- 
titis is  characterized  by  a hyperemia  of  the  mucous  mem- 
brane of  the  mouth,  the  gums  and  the  mucosa  of  the  cheeks. 
Later,  swelling,  hyperesthesia  and  tenderness  of  the  organs 
of  mastication,  supervene,  together  with  an  increased  dis- 
charge of  the  secretion  of  the  parotis  and  submaxillary 
glands,  probably  in  consequence  of  the  inflammatory  ex- 
citement of  the  chorda  tympani  and  sympathicus.  Another 
cause  of  the  above  condition  may  be  the  chemical  alteration 
of  the  saliva  in  the  mouth,  which  induces  an  excited  irrita- 
tion of  the  mucous  membrane  of  the  tongue,  fauces  and 
oesophagus. 

2.  The  stomatitis  ulcerosa  diptheriticais , named  by  me 
as  the  second  form,  properly  deriving  its  name  from  the 
gangrenous  tendency  of  the  ulceration  of  the  mucous  mem- 
brane of  the  mouth,  which  is  covered  with  a dirty  yellow, 
resembling  a diphtheritic  membrane.  This  is  markedly  the 
case  around  the  last  tooth,  and  the  fold  produced  at  the 
angle  of  the  jaw  by  mastication  ; also  on  the  borders  of  the 
tongue  and  cheek  pressed  by  the  teeth. 

3.  The  ptyalism  proper  may  be  characterized  as  an  in- 
crease in  the  flow  of  saliva  in  the  absence  of  even  any  inflam- 
matory appearance , without  being  changed  any,  or  but  little, 
in  quality. 

In  the  experimental  phase  of  my  subcutaneous  method,  I 
hailed  these  increased  affections  of  the  mouth  as  signs  of 
established  absorption  of  the  sublimate,  and  I did  not  inter- 
fere on  account  of  studying  the  hyper-secretory  effect  upon 
the  lues  and  its  recidives . 

It  is  only  attributable  to  that  cause  that,  with  the  four 
hundred  patients  subcutaneously  treated,  and  who  have 
been  the  material  for  my  first  publication,  the  high  figures 


28  APPEARANCES  OCCURRING  AFTER  INJECTIONS. 


of  35  per  cent,  were  possessed  of  mercurial  mouth  affec- 
tions. But  soon  I was  convinced  that  this  stomatitis,  in- 
stead of  having  a healthy  effect,  was  hurtful,  emaciated  the 
patient,  took  his  strength  and  made  it  difficult  to  replace 
this  waste;  also,  as  Sigmund  says  correctly,  that  “even 
the  lungs  may  become  injured  by  the  cadaverous  odor  of  the 
mouth.” 

As  salivation,  on  the  one  hand,  promotes  absorption  of  the 
syphilitic  hyperplasia , so,  on  the  other  hand,  the  sequela 
due  to  the  disease  showed  clearly  that  often  no  radical  cure 
was  effected.  And  very  often  the  treatment  had  to  be  in- 
terrupted for  days  and  even  weeks.  Among  the  one  hundred 
and  forty-four  named  cases  of  mercurial  stomatitis,  which 
were  noticed  in  two  hundred  and  fifty-six  women,  in  seventy- 
nine  cases  the  injections  had  to  be  suspended  on  account  of 
the  mouth  affection.  This  interruption  consisted  of  five 
hundred  and  eighty-eight  days,  or  an  average  of  seven  days 
per  person.  It  is  well  known  that,  aside  from  the  disturb- 
ance of  the  nutritive  functions,  salivation,  when  once  inau- 
gurated, may  advance  to  such  a degree  that  permanent 
injury  may  occur  to  the  teeth,  bones,  soft  parts,  &c. ; 
therefore,  I need  not  point  out  the  dangers  occurring  from 
such  a state  of  things ; and  for  this  reason,  the  chief  aim  of 
the  physician  should  be,  in  every  mercurial  cure,  as  also  with 
the  subcutaneous  method,  not  only  to  quickly  check  saliva- 
tion, but  to  anticipate  and  prevent  it. 

The  first  aim  is  to  use  curative  means,  and  then  prophy- 
lactic. Prophylaxis  concerns  such  persons  as  are  predis- 
posed to  salivation ; also  such  patients  as  cannot  withstand 
remedies  unsuited  to  their  organisms ; e . <7.,  delicate,  anae- 
mic, leucaemic  and  lymphatic  constitutions. 

This  is  why  women  are  more  apt  to  have  stomatitis  than 


GENERAL  SYMPTOMS. 


29 


men.  The  frail,  delicate,  and  those  laboring  under  existing 
dyscrasia,  and  persons  who  have  either  lived  in  unhealthy 
surroundings,  or,  on  the  other  hand,  have  lived  too  high, 
are  the  ones  affected. 

To  order  good  diet  and  to  have  proper  food  adapted  to 
our  cure,  to  ventilate  well  the  different  rooms,  is  as  much  a 
factor  in  preventive  therapeutics  as  the  regularity  of  all  the 
functions  of  the  body  by  the  suitable  use  of  saline  laxatives 
— such  as  magnesia,  the  various  salts,  sulphur  baths,  &c. 

The  care  of  the  teeth  demands  increased  diligence,  and 
Sigmund  has  given  us  exact  rules  thereon : 

Repeated  cleansing  of  the  mouth,  and  especially  of  the 
teeth  and  gums,  should  be  observed ; gargling  with  a solu- 
tion of  alum  5i  ad  Sxvj  of  distilled  water.  If  bleeding 
should  be  lightly  induced,  apply  tincture  of  rhatany  as  a 
lotion;  and  if  painful,  use  tincture  of  opium  in  the  same 
manner.  Extract  decayed  teeth,  if  any;  and  restrain  the 
patient  from  wearing  false  teeth,  if  possessed  of  them. 

John  Hunter,  long  ago,  pointed  out  how  a necrosed  root 
in  the  alveola  process  produced  salivation. 

In  hospital  practice,  it  is  not  easy  to  fix  these  rules  and 
have  them  fully  obeyed  ; but  in  private  practice  I was  sel- 
dom called  upon  to  adhere  to  them  rigorously,  salivation 
being  so  very  much  less  frequent. 

The  warm  weather  of  summer,  and  being  much  in  the 
open  air,  seems  a preventive  of  ptyalism,  while  the  winter 
weather  predisposes  the  patient  to  it.  Those  patients  par- 
ticularly, according  to  my  observations,  who  have  a diathesis 
predisposed  to  mercurial  stomatitis , will  need  to  be  regulated 
in  accordance  with  these  rules. 

The  best  remedy  to  prevent  or  combat  salivation  has 
been,  in  my  experience,  chlorate  of  potash,  as  recom- 

3* 


30  APPEARANCES  OCCURRING  AFTER  INJECTIONS. 


mended  by  Herpin,  Blache  and  others.  The  other  rem- 
edies, recommended  by  different  authors,  such  as  camphor, 
some  of  the  preparations  of  sulphur,  sulphuric  acid  (used 
by  Lagneau  as  a lemonade-like  drink),  and  iodide  of  potas- 
sium, often  had  either  no  effect  at  all,  or  but  little. 

As  soon  as  approaching  signs  of  salivation  appear,  I let 
my  patient  gargle  with  solution  of  chlorate  of  potash,  gr. 
x.  to  the  fluid  ounce  of  water.  Internally,  according  to 
intensity  of  symptoms,  I use  a solution  of  double  strength,  a 
tablespoonful  to  be  taken  every  one  or  two  hours.  If  there 
should  be  much  inflammation,  I use  a solution  of  gum-arabic 
and  opium.  Avoid  a too  concentrated  solution  of  alum  or 
tannin,  because  both  astringents  are,  according  to  Magitot’s 
experiment  (Gaz.  Med .,  No.  32,  1866),  injurious  to  the 
teeth ; the  first,  by  destroying  the  enamel ; the  latter,  by 
affecting  the  dentine.  Only  i,n  ptyalism  proper  is  tannin  to 
be  preferred  as  an  astringent. 

But  if  other  inflammatory  symptoms  have  set  in,  espe- 
cially on  the  mucous  membrane  of  the  mouth,  the  use  of 
nitrate  of  silver  is  indicated,  at  the  same  time  diminishing 
the  doses  of  the  sublimate  injection,  or  even  suspending  the 
treatment  for  one  or  more  days,  until  the  symptoms  abate. 

I noticed  mouth  affections  to  occur  more  quickly  in  those 
patients  whom  I treated  with  my  “ Combination  Cure” 
which  I shall  hereafter  bring  to  your  notice.  These  patients 
either  had  undergone  a mercurial  cure  before  coming  to  me , 
or,  with  the  subcutaneous  injection , a so-called  “ Sarsaparilla 
Sweat  Cure  ” had  been  instituted . Especially  soon  did  the 
mouth  affections  appear  in  such  as  took  internally  the  iodide 
of  potassium  conjointly  with  my  treatment . Whether  sali- 
vation was  hereby  produced  by  quicksilver  being  eliminated 
in  the  form  of  iodide  of  mercury,  soluble  in  the  alkaline 


GENERAL  SYMPTOMS. 


SI 


serum  of  the  blood,  or  whether  the  known  effect  of  iodide  of 
potassium  on  the  secretory  glands  of  the  mucous  membrane 
of  the  nose  and  eyes  was  brought  about,  forming  here  coryza 
and  blennorrhagia  of  the  conjunctive,  working  in  the  same 
manner  on  the  glandular  apparatus  of  the  mouth — I cannot 
decide,  but  leave  it  to  further  chemical  and  physiological 
experiments. 

Persons  exercising  much  in  the  open  air  are  not  so  sus- 
ceptible to  the  affections  following  slight  colds,  such  as 
slight  inflammation  of  the  lymphatic  glands , and  glands  of  the 
pharynx  and  submaxillary  region . 

Patients  complain  of  pain  in  their  throat,  especially  when 
swallowing,  and  inspection  reveals  redness  and  swelling  of 
the  tonsils  and  enlargement  of  the  submaxillary  lymphatic 
glands,  which  are  pained  by  pressure,  as  is  seen  in  common 
diphtheria.  The  symptoms,  however,  never  got  so  aggra- 
vated that  interruption  of  the  cure  was  necessary.  Gargles 
of  emollient  decoctions  with  opium,  or  slight  pencilings  with 
nitrate  of  silver  were  sufficient. 

In  hypertrophy  of  the  tonsils , an  occurrence  often  met 
after  a successful  subcutaneous  cure,  I only  use  local  means, 
and  mostly  nitrate  of  silver.  When  there  is  a tendency  to 
inflammation  and  ulceration  of  the  mucous  membrane  and 
alveoli,  I use  the  same.  In  case  the  interstitial  tissue  is 
tense  and  hyperplastic,  causing  hypertrophy  of  the  tonsil,  I 
use  the  crystals  of  chromic  acid,  and  apply  them  on  the 
surface,  letting  them  melt  there.  This  will  cause  a yellow- 
brown  soft  mass,  which  can  be  removed  after  a time,  or 
when  we  wish  to  make  a future  application.  If  in  this  man- 
ner part  of  the  tonsils  are  destroyed,  the  remaining  tissue 
shrinks  and  causes  an  immunity  against  future  inflammatory 
hyperaemia. 


32  APPEARANCES  OCCURRING  AFTER  INJECTIONS. 

This  same  treatment  I have  instituted  with  persons  having 
a slight  cold  with  tonsillitis  catarrhalis,  with  a success  most 
gratifying. 

b.  Disturbances  of  Respiration  and  Circulation . — Con- 
cerning the  influence  of  the  sublimate  on  the  organs  of  res- 
piration and  circulation — how  much  the  same  may  give  rise 
to  inflammation,  or  figure  in  producing  anginose  symptoms, 
and  to  what  extent  it  may  increase,  or  induce  tuberculosis — 
are  questions  we  may  put  aside,  if  our  assurance  is  sufficient 
that,  in  individuals  with  disease  of  the  respiratory  apparatus, 
or  even  with  tuberculosis,  we  prefer  our  cure  to  any  other, 
as  we  shall  more  fully  point  out. 

c . Disturbances  of  the  Urinary  Organs . — The  English 
physician  Pavy  stated,  as  a fact  well  known,  that  mercury 
had  a strongly  deleterious  effect  on  the  kidneys.  But  I can 
say,  from  my  own  experience,  that  I never  noticed  that 
effect  from  the  sublimate  injections.  I have  not  hesitated  to 
go  so  far  in  some  cases,  complicated  with  albuminuria  and 
mellituria,  as  to  inject  this  solution  with  good  results.  I 
will  remark  here  that,  notwithstanding  mercury  was  to  be 
found  in  the  urine,  I never  could  detect  in  mercurial  urine, 
albumen,  as  Kletzinsky  asserts ; neither  could  I detect 
sugar,  even  in  cases  where  the  sublimate  had  been  used  for 
a long  time,  expecting  it,  as  I did,  according  to  the  experi- 
ments of  Laikowsky. 

I may  further  add,  that  I never  saw  arise  an  affection  of 
the  bladder , or  urethra , and  we  may  positively  say  that  the 
whole  uropoetic  system  remains  undisturbed  by  the  use  of 
sublimate  injections. 

d.  Disturbances  in  the  Functions  of  the  Shin  and  Hair . — 
Of  the  injurious  effects  of  the  sublimate  on  these  just  men- 
tioned parts,  which  effects  play  quite  a roU  in  hydrargyrosis , 


GENERAL  SYMPTOMS. 


33 


we  had  not  a single  case  to  record.  My  patients  remained 
free  from  the  mercurial  eczema  which  always  attends  the 
“ rubbing  cure,”  as  a troublesome  companion;  and,  also, 
erythema  furunculus  was  never  witnessed,  complications 
which  sometimes  arise  from  the  internal  use  of  hydrargyrum . 
On  the  contrary,  our  injection  healed  relatively  quickly 
deep-seated  syphilitic  ulcerations  of  the  skin,  without  caus- 
ing any  erosions  whatever.  Neither  had  a single  patient  of 
mine  that  idiosyncracy,  according  to  some  writers,  which 
gives  rise  to  a peculiar  dermatitis,  and  is  a contra-indication 
for  every  use  of  mercury. 

Concerning  the  affection  termed  “ mercurial  alopecia” 
(the  falling  out  of  the  hair),  a number  of  patients  complained 
of  it  at  the  beginning  of  the  treatment;  but  these  symptoms, 
wrongly  attributed  to  the  mercury,  disappeared  as  the  cure 
advanced. 

In  very  many  of  my  patients  I noticed  an  increased  ac- 
tivity of  the  perspiratory  glands  of  the  skin,  especially  at 
night;  but  whether  there  were  other  reasons  for  it  than  the 
subcutaneous  injections  of  the  corrosive  sublimate,  could  not 
be  ascertained. 

e.  Disturbances  in  the  Osseous  System . — Diseases  of  the 
bones  have  always  received  a large  share  of  attention  from 
writers  on  the  effects  of  mercury.  Their  preconceived  ideas 
were  based  on  wrong  quotations  and  uncertain  observations. 
I myself  had  an  ample  opportunity  to  observe  and  treat 
diseases  of  the  bones ; but  in  no  single  instance  could  I pro- 
nounce them  to  be  the  result  of  mercury ; and  I never  saw 
symptoms  arise  as  observed  by  Dieterich,  and  called  by  him 
“symphoresis  periostei  mercurialis”  — congestion  of  the 
periosteum  from  mercury. 

/.  Disturbances  in  the  Formation  of  Blood . — Neither 


34  APPEARANCES  OCCURRING  AFTER  INJECTIONS. 


chemical  nor  microscopical  examinations  of  the  blood  of 
mercurialized  patients,  revealed,  for  certain,  a deficiency  in 
the  red  corpuscles , nor  in  the  albumen.  It  is,  nevertheless, 
true  that  mercury  deeply  affects  nutrition,  depresses  it  and 
produces  a kind  of  cachexia,  a form  of  which  is  chlorosis 
and  anaemia . According  to  these  observations  but  few  of 
my  patients  complained  of  loss  of  strength,  nor  did  I have 
but  few  affected  with  chlorosis.  Those  affected  with  com- 
plaints of  that  kind  were  patients  where  large  doses  for  a 
longer  or  shorter  time  had  been  used.  I generally  paused 
with  the  hypodermic  injections  until  those  symptoms  disap- 
peared, when  I resumed  treatment  again.  I never  noticed 
that,  after  a longer  or  shorter  duration  of  the.  treatment, 
symptoms  appeared  which  could  be  connected  with  diseased 
blood.  Mostly  my  treatment  ended  without  any  of  those 
disturbances.  Neither  had  I any  occasion  to  notice  other 
alterations  of  the  blood,  more  closely  or  remotely  connected 
with  mercurial  dissolution  of  the  blood,  symptomized  by 
epistaxis , hemorrhage  of  the  rectum  or  uterus , disturbances 
of  the  latter  organ , resulting  in  amenorrhoea , dysmenorrhoea , 
<fc.  The  hot  summer  months  and  the  overcrowded  rooms  in 
the  hospitals  would  surely  have  been  predisposing  causes  to 
such  hemorrhages.  I failed  to  observe  any  change  in  the 
catamenia,  the  female  patients  being  undisturbed  in  this 
respect,  although  I used  the  injection  during  menstruation. 

One  observation  I will  not  pass  over  in  silence,  beeause 
it  might  be  classed  under  the  head  of  blood  affections. 
With  some  patients,  I observed,  from  six  to  twelve  hours 
after  injection,  ecchymosed  patches , surrounded  by  a pale 
red  circle , on  different  parts  of  the  body,  and  of  the  size  of  a 
pin's  head  up  to  an  inch  in  diameter.  As  suddenly  as  they 


GENERAL  SYMPTOMS. 


35 


appeared  they  disappeared  again,  sometimes  getting  paler, 
and  followed  by  a desquamation  of  the  epidermis. 

They  but  slightly  inconvenienced  the  patient  by  itching, 
and  when  they  appeared  after  every  symptom  of  syphilis 
was  gone,  they  frightened  the  patient,  taking  the  eruption 
for  a relapse  of  the  disease.  These  patches  disappear  with- 
out any  local  treatment,  and  I am  not  disposed  to  take  them 
for  purpura , produced  by  mercurial  dissolution  of  the 
blood.  I have  learned  to  regard  them  as  partial  symptoms 
of  advanced  syphilis,  an  opinion  proved  correct  by  the 
result  of  the  injection  cure. 

This  observation  may  be  a corroboration  of  the  assertion, 
doubted  by  few  authors,  that  syphilis  proper , not  modified  by 
medical  interference,  can  bring  about,  through  metabolic 
changes  of  the  blood’s  albumen,  a lessening  of  the  blood 
corpuscles,  developing  the  appearances  of  chlorosis  and 
ancemia , and  such  symptoms  as  were  above  described  as 
belonging  to  mercurialized  persons.  With  persons  of  that 
kind,  who,  with  disturbances  of  some  organs,  had  a cachectic 
appearance,  the  sublimate  worked  in  a wonderful  and  sur- 
prisingly radical  way,  changing  them  so  that  after  the  treat- 
ment was  ended  they  seemed  hardly  the  same  persons. 

g . Disturbances  of  the  Nervous  System . — A glance  into 
the  literature  on  this  particular  branch  (and  I will  name 
here  only  the  valuable  works  of  the  learned  scientist,  Kuss- 
maul),  shows  how  diffused  the  picture  is  of  what  is  commonly 
called  mercurial  neurosis  and  psychosis , and  how  contra- 
dictory the  symptoms  are.  It  is  not  yet  demonstrated 
whether  mercury  itself  causes  these  disturbances,  whether 
they  result  from  impaired  nutrition  and  deteriorated  blood, 
or  whether  these  diseases  are  sequences  from  heterogeneous 
causes. 


36  APPEARANCES  OCCURRING  AFTER  INJECTIONS. 

My  patients  generally  showed  no  symptoms  that  could  be 
attributed  to  mercury  causing  alteration  of  the  functions  of 
either  the  sensitive  or  motor  nerves.  We  had  neither  anaes- 
thesia, nor  hypercesthesia , nor  spasm , nor  convulsion  to  com- 
bat. None  of  our  patients  showed  signs  of  spinal  or  cerebral 
paralysis.  We  cannot  report * a dizziness  in  the  form  of 
vertigo  mercurialis,  nor  swooning.  We  cannot  chronicle  a 
case  of  psellismus,  nor  of  aphonia.  We  have  not  witnessed 
either  epileptiform  or  apoplectic  attacks.  Only  in  four  cases 
did  I observe  anything  simulating  a nervous  disturbance. 
In  three  we  designated  a mercurial  tremor ; in  the  fourth, 
what  is  termed  mercurial  erethism.  The  first  three  were 
individuals  of  a healthy,  robust  constitution.  We  observed 
a tremor  of  a slight  character  in  the  outstretched  hands, 
after  fifteen  to  twenty-five  injections  of  £ gr.  each. 

The  case  of  erethism  occurred  in  a patient  who  received 
large  quantities  of  the  sublimate  subcutaneously,  and  who 
underwent,  without  our  knowing  it,  a “ hunger  cure,”* 
which  case  I shall  relate  more  fully  hereafter. 

We  used  our  treatment  even  in  drunkards  without  any 
untoward  changes  or  any  augmentation  of  their  tremors, 
which  we  shall  point  out  in  the  course  of  this  work. 

The  psychical  effect  of  mercury  we  noticed,  in  some  of  our 
female  patients,  by  a greater  sensitiveness  and  nervousness. 
Whether  this  was  occasioned  by  the  specific  effect  of  the 
drug,  or  whether  it  was  induced  by  the  pain  occurring  from 
the  daily  repetitions  of  the  injection,  we  cannot  say.  The 
male  patients  showed  these  symptoms  in  a less  degree,  and 

* The  11  hunger  cure”  has  been  used  in  some  hospitals  in  Germany  for 
the  last  ten  or  twelve  years,  as  an  anti-syphilitic  treatment,  suggested 
by  French  authorities,  and  very  much  practiced  in  France. — Transla- 
tor’s Rem. 


SYMPTOMS  OF  INTOXICATION. 


37 


therefore  we  are  inclined  to  think  the  individuality  of  our 
female  patients  had  much  to  do  with  this  psychical  erethism. 
So  have  I noticed,  among  the  educated  part  of  my  patients, 
that  very  many  showed  quite  a marked  change  in  their 
minds  for  the  better;  and  this  change  was  the  more  re- 
markable since  quite  a good  many  patients  are  very  de- 
spondent, almost  hypochondriac,  with  a venereal  disease. 
This  despondency  every  syphilographer  has  occasion  to  no- 
tice— a condition  equally  bad  for  the  patient  and  discour- 
aging for  the  physician.  Whether  it  was  due  to  the  quicker 
perception  of  better  feeling,  or  whether  mercury  has  a spe- 
cific effect  on  the  nerves,  we  are,  according  to  the  present 
state  of  our  science,  unable  to  tell. 

SYMPTOMS  OF  INTOXICATION. 

When  I come  to  the  conclusion  that  toxic  appearances  are 
not  significant,  and  are  infrequent,  I must  remind  the  reader 
that,  to  avoid  them,  he  must  cautiously  administer  the  medi- 
cine, in  accurate  doses,  as  pointed  out  by  me.  if,  on  the 
other  hand , the  maximum  doses  are  overstepped , then  acute 
sublimate  intoxication , as  I call  it,  occurs,  according  to  the 
individuality  and  quantity  of  injected  sublimate.  I shall 
try  to  characterize  the  intoxication. 

These  symptoms,  arising  in  such  cases  through  intoxica- 
tion, may  be  classed  as  clear  absorption  of  the  sublimate , 
and  interesting,  therefore,  because  their  character  does  not 
present  any  complication.  This  differs  from  the  internal 
administration  of  mercury  on  the  mucous  tissue  of  the 
stomach,  or  either  when  the  atmosphere  of  the  room  is  im- 
pregnated with  mercury,  and  it  enters  into  the  system  by 
inhalation,  or  when  it  enters  by  means  of  the  rubbing  cure. 

4 


38  APPEARANCES  OCCURRING  AFTER  INJECTIONS. 


The  totality  of  the  symptoms  in  our  intoxication  gives  the 
impression  of  malignant  g astro-enteritis , while,  in  point  of 
fact,  the  entire  intestinal  tract  is  unaffected  by  the  direct 
effects  of  the  drug.  In  lighter  cases,  the  intoxication  is 
ushered  in  by  gastric  disturbances  like  anorexia,  coated 
tongue,  bad  taste,  sometimes  metallic ; yet  but  seldom  does 
the  patient  complain  of  nausea  and  vomiting.  After  a little 
time,  pain  of  a sharp,  burning  character  is  experienced — 
symptoms  which  manifest  themselves  not  only  spontaneously, 
but  by  pressure  on  the  abdomen  especially,  and  in  the  re- 
gions of  the  stomach  and  right  hypochondrium.  A little 
later,  diarrhoea  commences,  tinged  with  blood  only  when 
occurring  profusely.  If  this  symptom  occurred  during  the 
day,  the  sleep  was  disturbed — often  interrupted  by  sudden 
waking  up.  These  patients  presented  a marked  pale  ap- 
pearance. The  conjunctiva  was  especially  pale,  the  eye  ap- 
pearing dull  and  the  face  wearing  a look  of  suffering.  They 
complained  of  great  languor,  and  after  walking  but^a  short 
distance,  they  were  obliged  to  sit  down  and  rest.  On  this 
account  many  remained  in  bed. 

The  secretions  showed  nothing  abnormal.  With  some, 
the  quantity  of  urine  was  increased,  lessened  in  specific 
gravity,  of  pale  straw  color,  without  any  abnormal  ingre- 
dients. 

Pulse,  narrow  and  flexed,  having  from  90  to  100  beats 
per  minute,  which  rose  to  130  by  slight  exertion.  After 
injections  of  relatively  greater  doses,  the  symptoms  were 
aggravated,  patients  generally  complaining  of  a vertiginous 
feeling , and  after  walking  a few  steps  they  would  feel 
obliged  to  seize  hold  of  something  for  support.  Even  in 
bed  these  symptoms  were  noticed,  with  comatose  complica- 
tions. Pulse,  immediately  after  injecting  the  sublimate,  was 


DIETETIC  RULES. 


39 


accelerated  and  wiry,  but  would  fall  down  to  60,  and  in 
one  case  to  40  beats  per  minute. 

The  skin  was  in  every  observed  case  without  any  turgor ; 
cool  to  the  touch,  and  often  covered  with  a clammy,  cold 
sweat.  Stronger  symptoms,  denoting  acute  gastritis,  oc- 
curred later.  With  the  already  painful  affection  of  the  ab- 
domen, vomiting  occurred,  sometimes  with  bloody  dysenteric 
stools  and  tenesmus.  Urine  was  voided  in  small  quantity ; 
but  nothing  abnormal  could  be  detected.  I never  noticed  a 
fatal  termination  of  such  cases,  nor  any  lasting  injury.  Res- 
toration came  about  under  appropriate  diet  and  treatment — 
the  disturbances  of  the  digestive  apparatus  improving  also. 
The  therapeutical  treatment  consisted  of  suitable  tonics  and 
nutritious  diet.  For  the  dysentery  we  used  opium  ; for  the 
vertigo,  excitants,  with  good  and  marked  results. 


IY.  DIETETIC  RULES. 

I.  CONCERNING  THE  BODY. 

As  remarked  previously,  our  cure  has  the  advantage  over 
all  others,  that  .it  does  not  confine  the  patient  to  bed  or  room. 
On  the  contrary,  I allow  all  my  patients  to  exercise  in  the 
open  air , when  the  weather  is  not  too  inclement,  only  cau- 
tioning them  against  the  morning  and  night  air,  and  di- 
recting them  to  wear  woollen  wrappers  and  drawers. 

Only  in  a few  cases  did  I notice  catarrhal  affections  in 
the  pharynx  and  larynx,  and  in  but  two  cases,  a heavy 
bronchitis,  both  being  patients  who,  contrary  to  my  orders, 
took  a long  walk  upon  an  icy,  cold  winter  day.  On  the 
whole,  it  seems  that  by  staying  in  a uniform  temperature 
during  the  entire  treatment,  cases  like  these  are  benefited — 


40 


DIETETIC  RULES. 


a fact  I had  occasion  to  notice  in  the  Charity  Hospital  and 
among  my  private  patients. 

The  same  freedom  prevails  in  the  dietetic  regime.  I never 
insist  that  my  patients  shall  fast,  as  is  the  case  with  many 
anti-syphilitic  treatments ; yet  it  is  certainly  best  to  have 
some  regulation  about  the  diet;  still  I never  employ  with  my 
cases  a routine  practice,  laying  down  certain  rules.  On  the 
contrary,  individuality  and  diathesis  are  my  guide,  and  I 
pay  a good  deal  of  care  to  such  persons  as  have  a chlorotic 
or  other  complication  with  this  venereal  affection. 

I classify  them  in  general  into  three  distinct  groups : 

1.  Robust. 

2.  Medium  strong. 

3.  Weak. 

As  a general  rule,  I do  not  allow  any  food  that  is  difficult 
for  digestion,  nor  do  I allow  a diet  which  will  produce  flatu- 
lence, hard  stools  and  constipation ; so  it  is  best  to  prohibit 
sour,  salty  and  spiced  victuals.  I observed,  in  the  course  of 
time,  that  it  required,  in  robust,  healthy  and  well-nourished 
individuals,  more  of  the  sublimate  to  produce  a favorable 
result.  I also  noticed  that  a complete  cure  was  not  estab- 
lished until  these  patients  began  to  lose  flesh.  For  this 
reason  I adopted,  in  later  cases,  a little  more  restriction  in 
diet;  and  when  I saw  that  completion  of  cure  was  not 
taking  place,  I employed  oftentimes  mild,  and  in  some 
instances  even  drastic  purgatives,  and  always  with  good 
success.  With  persons  of  the  second  class  I institute  a 
general  diet,  corresponding  to  such  as  they  are  used  to  at 
home,  with  perhaps  only  half  the  quantity  of  meat  for  din- 
ner, and  then  I prefer  the  white  meats  to  the  other.  For 
that  shortening  of  diet,  on  account  of  less  meat,  vegetables 
and  soups  may  be  allowed. 


CONCERNING  THE  BODY. 


41 


The  first  and  second  class  of  patients  I permit  to  use 
coffee,  tea,  cocoa,  &c.,  for  breakfast;  but  the  use  of  fer- 
mented liquor  is  strictly  prohibited,  and  only  in  very  excep- 
tional cases  do  I make  use  of  it.  I insist  strongly  that  none 
shall  be  used,  even  among  the  better  class  of  society,  when 
the  patient  has  been  habituated  to  it  for  years,  and  I never 
saw  any  untoward  result  arising  from  the  abstinence,  as  the 
future  history  of  my  cases  will  show.  In  very  exceptional 
cases  I allowed  light  Rhine  wine. 

I come  now  to  the  third  class  of  my  patients,  typified  by 
a decidedly  bad  nourishment.  I class  among  them  here  old 
persons,  debilitated  by  sickness,  &c.  They  have  to  be  espe- 
cially cared  for  as  to  diet,  because  it  seems  that  the  injec- 
tion of  the  sublimate,  in  such  subjects,  destroys  a part  of 
the  albumen  of  the  blood,  and  on  account  of  that  loss  a fur- 
ther debility  is  induced.  I allow  such  subjects  beef,  veni- 
son, eggs  in  sufficient  quantity,  besides  a glass  of  good  beer 
and  good  old  wine.  I not  only  allow  it,  but  strongly  re- 
commend it. 

As  with  other  anti-syphilitic  treatments,  the  skin,  urinary 
organs  and  intestines  have  to  be  watched,  but  not  as  closely 
as  in  other  methods,  since  our  treatment  does  not  induce  so 
much  secretion  there. 

I use,  in  the  incipiency  of  the  treatment,  the  bath  for  the 
patient,  in  order  to  induce  a free  action  of  the  skin , and 
follow  it  up  from  time  to  time.  Should  there  be  any  suspi- 
cion of  scrofulous  affection,  or  any  other  disease  of  the  skin, 
suitable  ingredients  for  the  bath  should  be  employed,  as 
ley,  &c. 

Concerning  the  urinary  organs , it  is  very  important  and 
beneficial  to  have  their  function  in  a proper  condition,  and 


4* 


42 


DIETETIC  RULES. 


slightly  diuretic  drinks,  as  the  carbonated  waters,  &c.,  are 
indicated. 

The  chylopoetic  viscera,  especially  the  stomach  and  intes- 
tines, ought  to  be  watched,  and  particularly  in  such  persons 
as  labor  under  habitual  obstruction,  attention  to  regular  mo- 
tion of  the  bowels  is  indicated.  Remedies  like  eonfectio 
sennce , or  a compound  infusion  of  senna , are  proper  reme- 
dies to  be  used,  care  being  taken  that  no  dysenteric  or 
diarrhoeal  condition  is  brought  about.  This  would  weaken 
the  patient  without  accomplishing  any  benefit.  In  only 
such  persons  as  are  fleshy  and  well  nourished,  as  I said  be- 
fore, should  drastic  purgatives  be  employed. 

Many  syphilitic  patients  have  a predilection  for  purging, 
thinking  it  will  assist  the  treatment.  Such  persons  should 
be  instructed  differently. 

II.  PSYCHICAL  CONSIDERATIONS. 

It  is  of  the  utmost  importance  to  be  quiet,  comfortable 
and  unirritated,  because  mercurial  erethism  may  result  from 
not  following  the  rules  laid  down  by  the  physician. 

It  is  with  many  sensitive  persons  a thing  of  no  small  im- 
portance that  they  experience  pain  with  each  injection — 
giving  rise  to  erethism.  It  is  doubly  necessary  that  such  per- 
sons avoid  all  excesses  and  mental  excitement.  But  should 
such  an  unfavorable  condition  be  unavoidable,  on  account  of 
family,  business  affairs,  &c.,  it  is  best  not  to  commence  the 
treatment  at  all. 

Here  I must  point  out,  once  again,  a favorable  sign  for 
our  treatment,  which  has  much  to  do  with  the  final  result. 
Patients  in  a very  depressed  state  of  mind  generally,  after 
the  first  injection,  would  give  way  to  a better  feeling , be- 
cause they  comprehend,  on  the  one  side,  a rapid  result,  and 


INDICATIONS  FOR  INJECTION. 


43 


on  the  other  side,  see  that  it  is  not  necessary  to  be  restricted 
to  bed  and  room,  nor  to  adhere  to  a rigid  diet.  All  these 
things  have  a salutary  influence  on  the  patient,  and  are 
clearly  in  favor  of  our  method. 

V.  INDICATIONS  FOR  INJECTION. 

Before  I shall  enumerate  more  thoroughly  the  indications 
for  our  treatment,  I think  it  necessary  to  state,  in  order  to 
avoid  misunderstandings,  that  I see  in  every  syphilitic  case 
a dualism. 

Therefore,  the  so-called  chancre , the  ulcus  molle , which, 
as  a primary  affection,  is  only  to  be  treated  locally,  and  not 
constitutionally,  must  be  separated  most  entirely  from  the 
genuine  syphilitic  sclerosis. 

The  virus  of  a primary  chancre  is,  according  to  its  local- 
ized condition  and  nature,  never  able  to  spread  any  further 
than  the  region  of  the  nearest  lymphatic  glands ; while  the 
poison  of  secondary  syphilis,  on  the  contrary,  has  the  pecu- 
liarity to  -enter  the  system  more  quickly,  infecting  the 
whole  organism  and  producing  injurious  indurations,  long 
before  it  could  have  succeeded  by  absorption  in  entering 
those  parts  of  the  body  where,  after  a relatively  protracted 
incubation,  every  trace  of  the  infection  is  swept  away  in  a 
hidden  manner. 

I do  not  think  it  necessary,  but  irrelevant,  to  repeat  all 
that  h?”  been  said  for  the  dualistic  conception  of  the  nature 
of  lues. 

Only,  then,  when  all  the  symptoms  have  been  taken  into 
consideration,  local  affections,  as  such,  will  be  differently 
judged,  and  practice  and  science  will  gain,  diagnosis  and 
therapeutics  having  a better  result. 


44 


INDICATIONS  FOR  INJECTION. 


I.  INITIAL  SYPHILIS. 

The  first  question  that  arises  is,  Is  primary  syphilitic  in- 
duration, not  accompanied  with  other  syphilitic  affection , 
except  swelled  inguinal  glands , a disease  for  sublimate 
injections  ? 

The  question  is  not  very  easy  to  answer  with  precision. 
Our  most  experienced  authors  are  not  yet  certain  whether 
the  initial  sclerosis  ought  to  he  treated  on  a general  anti- 
syphilitic plan.  Professor  Sigmund,  of  Vienna,  writes  as 
follows : “ Lighter  forms  of  syphilis,  especially  in  not  very 
healthy  subjects — as  simple  induration  with  small  papulous, 
superficial,  broken-down  tissue,  and  infiltration  of  the  neigh- 
boring lymphatic  glands,  with  progressing  indolent  swelling 
of  more  distant  glands,  and  erythema  of  the  mucous  parts  of 
the  mouth,  without  giving  rise  to  other  symptoms  in  other 
organs — need  only  a local  treatment,  and  are  often  cured 
spontaneously . But  to  come  to  a definite  conclusion  re- 
quires long  time  for  observation . I take  from  three  to  four 
months  as  an  average  time  for  observation,  since,  experience 
has  taught  me  that  within  this  time,  if  the  infection  has  not 
been  previously  eradicated,  it  assumes  a new  phase.” 

To  my  mind  the  whole  thing,  as  above,  is  uncertain  and 
unsatisfactory,  and  seems  to  be  derived  from  a very  super- 
ficial observation.  Such  assertions  can  only  be  proved  by 
authenticated  statistical  facts.  And  it  seems  to  me  it  de- 
mands a greater  material  for  observation  to  make  it  valuable 
for  statisticians.  And  the  material  of  casual  statistics,  by 
which  the  spontaneous  disappearance  of  syphilitic  sclerosis 
could  be  accurately  ascertained,  is  entirely  wanting  in  our 
syphilographic  literature.  It  is  for  this  reason  our  patients 
pay  no  attention  to  the  incipient  nodule.  Not  only  non- 


INITIAL  SYPHILIS. 


45 


professional  men  fall  into  that  error,  but  even  medical  men 
and  students,  none  of  whom  have  paid  scarcely  any  attention 
to  the  primitive  appearances  of  the  papules,  either  not  seeing 
them,  or  if  they  did,  they  regarded  them  as  irrelevant,  and 
employed  no  prophylactic  treatment. 

Patients  only  seek  for  help  when  the  neglected  sclerosis 
results  in  ulceration  and  other  threatening  symptoms. 

It  is  here  that  the  second  stage  of  incubation  is  partly  or 
wholly  commenced,  and  the  blood  is  already  venereally 
affected,  as  shown  by  the  fauces  and  exanthematous  erup- 
tion on  the  skin.  Directly  real  statistical  proof  and  facts  I 
cannot  give  for  my  views,  which  cannot  be  expected,  on  ac- 
count of  the  course  the  initial  affections  take ; but  I have 
data  which  will  strongly  support  my  opinion. 

For  the  last  eighteen  months,  in  which  I devoted  my 
attention  to  the  point  in  question,  I made  observations  on 
eight  hundred  patients  in  the  Charite  Hospital,  who  suffered 
with  genital  ulcerations.  Of  that  number  five  hundred  and 
seventy  showed  the  soft  chancre,  with  its  consequences  and 
combinations — the  rest  having  syphilitic  general  diseases, 
with  or  without  sclerosis  on  the  genitals. 

Initial  syphilitic  effects  were  only  present  in  nine  per- 
sons, and  with  six  the  sclerotic  process  showed  already  a 
tendency  of  commencing  destruction.  In  two  cases  the 
diagnosis  of  ulcus  durum  (hard  chancre)  could  be  made  out 
with  a probable,  but  not  with  an  absolute  certainty. 

This  great  rarity  of  initial  sclerosis,  in  its  isolated  appear- 
ance, its  coincidence  and  its  combination  with  the  more  pro- 
gressed general  syphilitic  symptoms,  such  as  glandular 
swellings,  exanthematous  affections  of  the  mouth,  &c.,  seems 
to  be  the  positive  proof  that  a spontaneous  healing,  without 


46 


INDICATIONS  FOR  INJECTION. 


a sufficient  general  therapeutical  treatment,  occurs  but  very 
seldom. 

Zeissl  confirms  these  views  of  mine  somewhat,  in  saying : 
u If  the  commencement  of  syphilitic  affections  is  not  altered 
by  therapeutical  means,  the  whole  run  of  the  changes  of 
syphilis,  with  more  or  less  interruption,  is  gradually  devel- 
oped. By  great  care  of  the  patients,  the  symptoms  may 
disappear  spontaneously ; and  if  the  symptoms  of  disappear- 
ance may  be  taken  for  a cure,  it  is  certainly  right  to  assert 
that  syphilis  may  heal  itself ; but  I never  yet  saw  a case 
where , with  spontaneous  healing  of  the  earliest  constitutional 
symptoms  of  the  disease , the  disease  itself  was  eradicated , 
and  where  it  did  not  lead  to  disturbances  of  other  vital 
organs 

As  I am  of  the  same  opinion,  I think  it  not  only  justifia- 
ble, but  even  highly  advisable,  to  use  the  sublimate  injection 
where  the  initial  symptoms  of  sclerosis  appear.  And  fur- 
ther, the  perfect  cure  of  the  disease,  whose  continuance  is 
dangerous,  on  account  of  a very  probable  and  possible 
relapse,  is,  and  ought  to  be,  the  main  therapeutical  point. 
The  curability  of  the  indurations  is  not  in  proportion  to 
their  continuance.  I will  give  one  example  in  illustration. 

In  a workman  thirty-six  years  of  age  I found  an  indura- 
tion of  three  years’  standing.  He  had  used  the  mercury 
treatment  of  Dzondi  and  Zittmann,  and  still  the  induration 
remained  of  considerable  size.* 

* The  decoction  of  Zittmann  (Decoctum  Zittmanni)  is  a preparation 
of  sarsaparilla,  much  used  in  Germany  for  purposes  similar  to  the  use 
of^our  “Compound  Decoction  of  Sarsaparilla/7  and  as  it  has  attracted 
some  attention  in  this  country,  as  a remedy  in  obstinate  ulcerative  affec- 
tions, we  give  the  formula  of  the  Prussian  Pharmacopoeia,  which  is  gen- 
erally followed  in  its  preparation. 

Take  of  sarsaparilla  12  oz.,  spring  water  90  lbs.;  digest  twenty-four 


CONDYLOMATA  LATA. 


47 


The  nature  of  this  sclerosis  showed  itself  after  three 
months  in  the  further  development  of  syphilis  in  the  form  of 
broad  papules  around  the  scrotum  and  anus,  together  with 
a syphilitic  eruption  on  the  body,  swelling  of  the  tubera 
frontalia , wThich  tormented  him  nightly  in  attacks  of  dolores 
osteocopei  (“  bone  ache’’).  On  that  account  I think  a mild 
and  moderate  treatment  by  injections,  in  cases  of  surely 
syphilitic  indurations,  very  proper. 

To  wait  three  or  four  months , looking  for  further  devel- 
opments of  syphilis,  as  Sigmund  advises,  under  the  super- 
vision of  a physician  for  that  length  of  time, — it  seems  but 
few  patients  would  submit  to  it. 

II.  CONDYLOMATA  LATA. 

Of  a greater  and  a more  valuable  importance  in  practice 
is  the  second  question,  viz. : Are  broad  condylomata — well 
known  as  the  first  syphilitic  symptom  in  woman — as  much 
an  indication  for  injections  of  sublimate  as  are  syphilitic  in- 
durations of  tissue  ? I consider  this  question  of  more  im- 
portance than  the  first  one,  because  it  is  met  in  private,  and 

hours ; then  introduce  in  a closed  bag  1J  oz.  of  sugar  of  alum  (saccha- 
rum  alumnis — seu  saccharum  aluminatum),  consisting  of  equal  parts 
of  pulverized  alum  and  the  whitest  sugar,  J oz.  of  calomel  and  1 dr. 
cinnabar.  Boil  down  to  30  lbs.,  and  near  the  end  of  the  boiling  add  of 
anise  seed  and  fennel  seed  each  J oz.,  senna  3 oz.,  licorice  root  1^  oz. 
Put  aside  the  liquid  under  the  name  of  u strong  decoction.”  To  the 
residue  add  of  sarsaparilla  6 oz.  and  90  lbs  spring  water.  Boil  down 
to  30  lbs.,  and  near  the  end  of  boiling  add  lemonpeel,  cinnamon,  cardo- 
mon  seed  and  licorice  root  each  3 dr.  Strain  and  set  aside  the  liquid 
under  the  name  of  u weak  decoction.”  Mercury  was  detected  in  this 
decoction  by  Wiggins  in  very  small  proportions.  It  should  not  be  pre- 
pared in  metallic  vessels,  lest  the  mercurial  solution  should  be  decom- 
posed. The  decoction  may  be  freely  taken. — Translator’s  Rem. 


48 


INDICATIONS  FOR  INJECTION. 


in  hospital  practice  very  much  more  frequently.  Very  often 
we  find  female  patients  suffering  from  broad  condylomata, 
but  seldom  do  they  themselves  apply  voluntarily  for  treat- 
ment, since  they  think  the  affection  devoid  of  danger. 

Here  in  Berlin,  where  prostitutes  are  compelled  by  law 
to  undergo  a weekly  examination,  all  having  condylomata 
lata , without  any  other  affection,  are  sent  right  off  to  the 
syphilitic  wards  of  the  Charite  Hospital. 

Before  entering  upon  the  treatment  of  this  affection,  I 
wish  to  state  my  views  in  regard  to  its  nature.  I believe 
condylomata  lata  to  be  an  undoubted  partial  appearance  of 
constitutional  syphilis  in  woman,  without  classing  them, 
either  histologically  or  chronologically,  under  the  same 
head  with  sclorosis  in  men. 

In  a former  work  of  mine  on  the  treatment  of  syphilis 
with  hypodermic  injections  of  sublimate  (Annals  of  the 
Charite  Hospital,  1868,  vol.  xiv.),  I endeavored  to  bring 
forth  my  views,  mostly  accepted  now,  on  the  constitutional 
syphilitic  nature  of  those  symptoms  in  woman,  and  to  defend 
them  against  a few  skeptics  like  Thiry  and  Soresina.  I en- 
deavored to  show  there  especially  the  coincidence  of  broad 
condylomes  with  other  grave  diseases  of  constitutional 
syphilis,  and  have  given  statistical  references,  and  ex- 
plained that  these  seemingly  local  affections  were  only  par- 
tial symptoms  of  general  syphilis,  and  must  not  be  con- 
founded with  slender  warts  or  vegetations.  The  latter  are 
always  a consequence  of  local  irritation ; while,  on  the  other 
hand,  the  broad  variety  develops  itself  differently.  To  sup- 
port that  supposition  for  the  here  so-called  secretory  begin- 
ning of  the  acuminata,  versus  the  condylomata  lata,  (i.  e.,  the 
moist,  versus  the  dry  variety),  more  observations  here  follow. 

In  women  in  the  latter  part  of  pregnancy,  and  in  many 


CONDYLOMATA  LATA. 


49 


who  were  recently  confined,  broad  warts*  are  developed, 
and  disappear  spontaneously  without  treatment.  The  other 
kind  (i.  e .,  slender  wart)  is  developed  under  the  same 
circumstances,  and  if  already  present  it  spreads  more 
quickly.  Metamorphosis  in  the  female  organism  being  at 
this  particular  time  more  rapid,  absorption  of  already  exist- 
ing exudation  and  broad  condylomes  were  favored,  and  pro- 
gressive transformation  hastened.  On  the  other  hand,  the 
acrid  secretion  of  pregnant  females  ( fluor  vaginalis)  and  the 
lochia  in  childbed  seems  to  assist  the  pointed  condylomes 
and  favor  their  rapid  spreading. 

In  the  section  quoted  in  my  previous  work,  I have 
strongly  urged  the  point,  which  gave  rise  to  much  misun- 
derstanding to  syphilographs,  and  for  which  explanation  only 
statistics  can  be  used,  viz. : I mean  the  proportion  in  which 
broad  condylomes  tend  to  initial  sclerosis . The  misunder- 
standing arose  from  this  cause : authors  like  Waller,  Linde- 
mann,  Rinecker,  Baerensprung,  Lindwurm,  Hebra,  &c., 
who  experimented  with  inoculations  of  secretions  of  second- 
ary syphilis,  had  a rather  loose  nosology,  and  named  indu- 
ration produced  by  inoculation , with  different  names, — and 
sometimes  used  the  word  papules , which  term  heretofore  had 
been  regarded  only  as  a synonyme  of  condylomata  lata . I 
find  another  point  corroborating  me  in  this  cause — that  the 
affection  named  by  me  as  sclerosis  in  woman  may  arise  more 
frequently  than  hitherto  supposed,  and  quite  a time  before 
the  development  of  broad  warts,  but  indeed  so  hidden  and 
in  such  places  in  the  female  sexual  organs  that  they  are 

* Called  by  Burastead  “ Vegetations — papillary  growths  springing 
from  the  skin  or  mucous  membrane,  chiefly  in  the  neighborhood  of  the 
genital  organs,  and  identical  in  their  nature  with  the  warts  found  so 
commonly  on  the  hand.” — Translator’s  Rem. 

5 


50 


INDICATIONS  FOR  INJECTION. 


hard  to  discover  on  account  of  their  anatomical  position  and 
configuration.  On  the  other  hand,  condylomes,  appearing 
later,  are  more  easily  visible  to  the  eye.  On  those  places 
which  are  in  juxtaposition  to  the  female  sexual  organs, 
during  the  physiological  act  of  coitus , and  where  direct  in- 
fection may  be  transmitted,  as,  for  instance,  the  labia  mi- 
nora, introitus  vaginae , commissura  posteriora , very  seldom 
are  detected  the  broad  condylomes ; but,  on  the  contrary, 
hidden  sclerosis  appears.  Other  places,  like  labia  majora , 
plicce  femoralis , regio  perinealis , places  never  directly 
touched  during  coitus,  are  the  most  favorite  localities  for 
the  eondylomata  lata , and  but  rarely  show  ulcus  molle  (the 
soft  chancre),  produced  by  direct  contact,  as  is  frequently 
the  case  on  the  labia  minora  and  introitus  vaginae. 

From  these  observations  I gradually  came  to  the  conclu- 
sion that  the  broad  warts  were  formed  quite  a time  subse- 
quent to  the  original  infection. 

The  time  condylomes  first  appear  is  generally  from  five 
to  ten  weeks  after  the  formation  of  an  induration.  If  we 
take  the  time  for  the  incubation  of  the  initial  sclerosis  as 
three  weeks,  it  is  clearly  evident  that  the  broad  condylomes 
will  make  their  appearance  in  from  eight  to  thirteen  weeks 
after  an  unhealthy  coitus. 

But  as  the  exanthema,  especially  of  the  maculous  kind, 
appears  in  six  or  seven  weeks  after  infection,  we  see  the 
lata , in  many  cases,  shortly  before  the  outbreak  of  the  ex- 
anthema, and  with  some  at  the  same  time. 

With  most  patients  affected  with  condylomes,  our  aim 
ought  to  be  not  only  the  treatment  of  the  local  affection, 
but,  in  addition,  to  combat  general  constitutional  symptoms, 
as  a product  of  those  excrescences.  This  is  the  reason  why 


CONDYLOMATA  LATA. 


51 


I instituted  the  injections  for  broad  condylomes , and  think 
this  treatment  justifiable  in  all  those  cases. 

I shall  employ  this  occasion  to  give  the  necessary  statis- 
tical proofs  of  the  seat  and  appearance  of  condylomata  lata, 
and  use  those  five  hundred  cases  which  I have  statistically 
arranged  in  my  previous  work,  because  the  other  observed 
twelve  hundred  cases,  which  are  the  basis  of  the  present 
work,  could  not  be  so  arranged  on  account  of  lack  of  time. 


A.  IN  WOMAN. 

I.  SEAT  OF  CONDYLOMATA  LATA. 

Of  the  356  women,  there  were  infected  with  condylomata 
lata , at  and  around  the  genitals,  280  persons  = 78.65  per 
cent.  If  we  reckon  in  here  those  who  had  condylomata  lata 
either  on  the  lips,  mouth  or  throat,  we  see  that  out  of  356 
women,  305  persons  = 85.67  per  cent.,  had  condylomata 
lata. 

The  special  seat  of  the  lata  was : 


A.  In  one  single  region  in  96  cases  = 31.47  per  cent. : 

Around  the  outer  genitals  in  56  cases  = 18  36  per  cent. 

In  the  throat  in  21  cases  = 6.88  per  cent. 

At  the  anus  in  13  cases  = 4.26  per  cent. 

At  the  lips  in  4 cases  = 1.31  per  cent. 

At  the  thigh  in  2 cases  = 0.65  per  cent. 

B.  At  the  same  time  in  two  regions  in  97  cases  = 31.8  per  cent.: 

At  the  genitals  and  throat  in  41  cases  = 13.44  per  cent. 

At  the  genitals  and  anus  in  35  cases  = 11.47  per  cent. 

At  the  genitals  and  inside  of  thigh  in  7 cases  = 2.95  per  cent. 
At  anus  and  throat  in  7 cases  = 2.29  per  cent. 

At  genitals  and  lips  in  2 cases  = 0.65  per  cent. 

At  genitals  and  tongue  in  1 case  = 0.33  per  cent. 


KSm »'  'uw0'8 


52 


INDICATIONS  FOR  INJECTION. 


At  genitals  and  between  toes  in  1 case  = 0.33  per  cent. 

At  lips  and  throat  in  1 case  = 0.33  per  cent. 

At  nose  and  lips  ) 

A , , , t no  cases. 

At  nose  and  throat  j 

C.  At  the  same  time  in  three  regions  in  74  cases  — 24.26  per  cent. : 

Genitals,  anus  and  throat  in  41  cases  — 13.44  per  cent. 

Genitals,  anus  and  bend  of  thigh  in  13  cases  = 4.26  per  cent. 
Genitals,  lips  and  throat  in  6 cases  = 1.95  per  cent. 

Genitals,  lips  and  bend  of  thigh  in  4 cases  = 1.34  per  cent. 
Genitals,  throat  and  nose  in  4 cases  — 1.34  per  cent. 

Genitals,  anus  and  lips  in  1 case  = 0.33  per  cent. 

Genitals,  throat  and  umbilicus  in  1 case  = 0.33  per  cent. 
Genitals,  throat  and  between  toes  in  1 case  = 0.33  per  cent. 
Genitals,  lips  and  nose  in  1 case  = 0.33  per  cent. 

Anus,  throat  and  nose  in  1 case  = 0.33  per  cent. 

Anus,  tongue  and  nose  in  1 case  = 0.33  per  cent. 

Lips,  tongue  and  throat  in  1 case  = 0.33  per  cent. 

D.  At  the  same  time  in  four  regions  in  27  cases  = 8.85  per  cent.: 

Genitals,  anus,  throat  and  bend  of  thigh  in  20  cases  = 6.55  per* 
cent. 

Genitals,  anus,  navel  and  bend  of  thigh  in  4 cases  = 1.30  per 
cent. 

Genitals,  tongue,  lips  and  throat  in  2 cases  = 0.65  per  cent. 
Genitals,  anus,  lips  and  throat  in  1 case  = 0.35  per  cent. 
Genitals,  anus,  lips  and  nose — no  case. 

E.  At  same  time  in  five  regions  in  8 cases  = 2.62  per  cent.: 

Genitals,  anus,  lips,  throat  and  bend  of  thigh  in  6 cases  = 1.95 
per  cent. 

Genitals,  anus,  navel,  throat  and  bend  of  thigh  in  1 case  = 0.33 
per  cent. 

Genitals,  anus,  navel,  throat  and  nose  in  1 case  = 0.33  per  cent. 
Genitals,  anus,  axilla,  throat  and  chest  in  1 case  = 0.33  per  cent. 
Genitals,  bend  of  thigh,  lips,  throat  and  nose  in  1 case  = 0.33 
per  cent. 

F.  At  same  time  in  six  regions  in  3 cases  = 0.85  per  cent.: 

Genitals,  anus,  bend  of  thigh,  navel,  lips  and  throat  in  1 case  = 
0.33  per  cent. 


CONDYLOMATA  LATA. 


53 


Genitals,  anus,  bend  of  thigh,  tongue,  lips  and  throat  in  1 case  = 
0.33  per  cent. 

Genitals,  between  toes,  bend  of  thigh,  chest,  neck  and  throat  in 
1 case  = 0.33  per  cent. 

Respecting  the  condition  of  the  broad  condylomes,  they 
appeared  with : 

Complete  epidermis  in  63  cases  = 22  per  cent. 

Eroded  epidermis  in  167  cases  = 59.64  per  cent. 

Very  much  ulcerated  in  35  cases  — 12.5  per  cent. 

In  the  remainder,  76  women,  who  showed  no  lata , the 
following  was  the  result  as  to  the  genitals : 

Hard  ulcers  in  15  cases  = 5.35  per  cent. 

Ulceration  of  an  indefinite  character  in  4 cases  = 1.42 
per  cent. 

Superficial  erosion  with  a certain  hardness  in  27  cases  = 
9.64  per  cent. 

II.  COMBINATION  OF  CONDYLOMATA  LATA  WITH  OTHER 
SYPHILITIC  AFFECTION. 

Exanthemata . — Of  280  women  infected  with  condylomes, 
combinations  with  exanthemata  were  in  233  persons  = 83.2 
per  cent. 

CASES.  PER  CENTAGE. 


Exanthema  maculosum  in  .... 

95 

40.77 

u 

maculo-papulosum 

38 

16.31 

u 

papulosum 

25 

10.73 

u 

maculo-papulo  squamosum 

21 

9 

u 

papulo  squamosum 

14 

6 

u 

maculo  squamosum 

12 

5.15 

u 

squamosum 

6 • 

2.57 

u 

maculo-papulo  squamo-pustulosum 

6 

2.57 

u 

papulo-squamo  condylomatosum  . 

3 

1.29 

u 

papulo-pustulosum 

2 

0.86 

a 

crustosum 

2 

0.86 

54 


INDICATIONS  FOR  INJECTION. 


CASES. 

Exanthema  maculo-squamo  crustosum  ...  2 

PER  CENTAGE. 

0.86 

U 

maculo-papulo  condylomatosum  . 

1 

0.43 

Cl 

papulo  condylomatosum 

1 

0.43 

Cl 

maculo-vesiculosum  .... 

1 

0.43 

a 

papulo-vesiculosum 

1 

0.43 

n 

squamo-pustulosum  . . 

I 

0.43 

Cl 

maculo-papulo  squamo  condylomato-crusto- 
sum  . . . ...  , • 

1 

0.43 

B.  IN  MEN. 

I.  SEAT  OF  CONDYLOMATA  LATA. 

Of  144  men,  there  were  infected  with  condylomata  lata 
on  the  genitals  58  persons  = 40.18  per  cent.  Taking 
those  who  were  affected  in  and  around  the  mouth,  we  have 
79  persons  = 54.86  per  cent. 

The  special  seats  were : 

A.  In  one  region  in  31  cases  = 39.23  per  cent. : 

In  the  throat  in  13  cases  = 1G.45  per  cent. 

At  the  anus  in  11  cases  = 13.92  per  cent. 

On  the  penis  in  2 cases  = 2.53  per  cent. 

On  the  scrotum  in  2 cases  = 2.53  per  cent. 

On  the  mouth  in  2 cases  = 2.53  per  cent. 

In  the  bend  of  the  thigh  in  1 case  = 1.26  per  cent. 

B.  In  two  regions  in  26  cases  = 32.91  per  cent.: 

On  the  scrotum  and  anus  in  6 cases  = 7.59  per  cent. 

On  the  throat  and  anus  in  6 cases  = 7.59  per  cent. 

On  the  throat  and  scrotum  in  3 cases  ==  3.79  per  cent. 

On  the  penis  and  scrotum  in  2 cases  = 2.53  per  cent. 

On  the  mouth  and  scrotum  in  2 cases  = 2.53  per  cent. 

On  the  mouth  and  throat  in  2 cases  = 2.53  per  cent. 

On  the  penis  and  anus  in  1 case  = 1.26  per  cent. 

On  the  penis  and  throat  in  1 case  = 1.26  per  cent. 

On  the  scrotum  and  axilla  in  1 case  = 1.26  per  cent. 


CONDYLOMATA  LATA. 


55 


In  the  mouth  and  tongue  in  1 case  = 1.26  per  cent. 

In  the  nose  and  throat  in  1 case  = 1.26  per  cent. 

C.  In  three  regions  in  13  cases  = 16.45  per  cent.  : 

Anus,  mouth  and  throat  in  3 cases  = 3.79  per  cent. 

Anus,  scrotum  and  throat  in  2 cases  = 2.53  per  cent. 

Anus,  scrotum  and  penis  in  1 case  = 1.26  per  cent. 

Anus,  scrotum  and  bend  of  the  thigh  in  1 case  = 1.26  per  cent. 
Anus,  scrotum  and  umbilicus  in  1 case  = 1.26  per  cent. 

Anus,  penis  and  throat  in  1 case  ==  1.26  per  cent. 

Anus,  bend  of  thigh  and  throat  in  1 case  = 1.26  per  cent. 

Anus,  bend  of  thigh  and  umbilicus  in  1 case  = 1.26  per  cent. 
Anus,  between  the  toes  and  throat  in  1 case  = 1.26  per  cent. 
Nose,  mouth  and  throat  in  1 case  = 1.26  per  cent. 

Tongue,  mouth  and  throat  in  1 case  = 1 26  per  cent. 

D.  In  four  regions  in  6 cases  = 7.59  per  cent. ; 

Scrotum,  anus,  bend  of  the  thigh  and  throat  in  2 cases  = 2.53 
per  cent. 

Scrotum,  anus,  mouth  and  throat  in  1 case  = 1.26  per  cent. 
Penis,  anus,  bend  of  thigh  and  throat  in  1 case  = 1.26  per  cent. 
Umbilicus,  anus,  bend  of  thigh  and  throat  in  1 case  = 1.26  per 
cent. 

Mouth,  anus,  tongue  and  throat  in  1 case  = 1.26  per  cent. 

E.  In  five  regions  in  3 cases  = 3.79  per  cent. : 

Penis,  scrotum,  mouth,  throat  and  anus  in  2 cases  = 2.53  per 
cent. 

Penis,  scrotum,  anus,  nose  and  throat  in  1 case  = 1.26  per  cent 


II.  COMBINATION  OF  CONDYLOMATA  LATA  AT  THE  GENITALS 
AND  SURROUNDINGS,  WITH  EXANTHEMATA. 

Of  58  men  affected  with  condylomata  lata , in  56  cases 
(=  96.55  per  cent.)  it  was  combined  with  exanthema  as 
follows : 

CASES.  PERCENTAGE. 

Exanthema  maculosum  in 18  31.03 

u papulo-squamosum  , 8 13.79 


56 


INDICATIONS  FOR  INJECTION. 


CASES.  PER  CENTAGE. 


Exanthema  maculo-squamosum  .... 

5 

8.62 

a 

maculo-papulo-squamosum  . 

5 

8.62 

it 

maculo-papulosum  .... 

4 

6.89 

a 

papulosum  . . . 

3 

5.17 

a 

papulo-pustulosum  .... 

3 

5.17 

a 

squamosum 

1 

1.72 

n 

crustosum  ...... 

1 

1.72 

a 

luposum  

1 

1.72 

a 

squamo-condylomatosum 

1 

1.72 

it 

condylomatosum-ulcerosum 

1 

1.72 

it 

maculo-papulo-crustosum 

1 

1.72 

a 

papulo-pustulo-crustosum  . 

1 

1.72 

a 

papulo-condylomato-pustulo  crustosum 

1 

1.72 

a 

maculo-condylomato-squamo-crustosum 

1 

1.72 

it 

papulo-squamo-luposum 

1 

1.72 

Further,  there  was  found  to  be 

Iritis  in  2 cases  ==  3.45  per  cent. 

Tophi  in  1 case  = 1.72  per  cent. 

III.  THERAPEUTICS  OE  SYPHILITIC  SCLEROSIS  AND  CONDY- 
LOMATA  LATA. 

Respecting  the  quantity  of  sublimate  for  a perfect  cure 
of  the  already  mentioned  initial  syphilitic  affection,  I must 
remark  here,  that  among  the  patients  treated  by  my  new 
method  but  very  few  were  affected  with  syphilitic  sclerosis 
simply.  The  greatest  number  had  several  other  syphilitic 
ailments,  so  that  it  was  more  a total  cure  of  general  syphilis 
than  a destroyer  of  the  single  initial  symptoms. 

The  indurations  showed,  in  many  cases,  a very  different 
degree  of  resistance  to  the  hypodermic  medication. 

In  most  cases  the  strength  of  this  resistance,  and  the 
grade  of  progress  in  the  treatment,  seems  to  be  in  propor- 
tion to  the  duration  of  the  already  present  affection,  for  the 


CONDYLOMATA  LATA. 


57 


sooner  the  injections  were  used  against  the  sclerosis,  the 
smaller  was  the  dose  necessary  for  a perfect  cure.  On  the 
other  hand,  the  longer  cases  had  delayed  in  applying  for 
treatment,  the  larger  was  the  quantity  requisite. 

In  the  majority  of  cases,  from  1J  gr.  to  2 gr.  of  the 
sublimate  were  sufficient  for  the  entire  cure  of  sclerosis. 
But  in  some  cases,  which  had  existed  for  quite  a time,  and 
where  large  indurations  had  been  formed,  greater  amounts, 
and  in  some  instances  4 gr.  were  hardly  sufficient.  The  in- 
tensity and  size  of  the  induration  simultaneously  lessened  with 
the  continuance  of  the  medication.  Only  in  exceptional 
cases  did  there  remain  any  infiltration  behind,  which  became 
softer,  still  differing  from  the  normal  surrounding  tissue  by 
its  hardened  consistence. 

It  was  extremely  difficult  to  get  rid  of  these  u cartilaginous- 
like  knots”  which  are  very  obstinate  in  resisting  every  mode 
of  treatment  and  medication,  a fact  well  known  to  all  syphil- 
ographers.  A very  concentrated  solution  of  the  sublimate 
seemed  to  me  the  most  effective  against  such  indurations. 
The  formation  begins  to  disappear  with  its  use,  sometimes 
even  in  a rapid  and  surprising  way,  so  that  the  extended 
skin  covering  the  elevated  knots  fails  to  collapse,  and  remains 
for  a while  loose,  like  a small  empty  pouch,  after  the  indu- 
ration vanishes. 

In  all  cases  where,  after  using  a middle-strong  solution  of 
sublimate,  an  unconquerable  “stand-still”  in  the  retro- 
gressive metamorphosis  seems  to  be  visible,  suspension  of 
the  treatment  for  a time  may  be  advisable.  We  have  had 
occasion  to  observe  that,  after  the  formation  was  again  re- 
produced, when  the  treatment  was  resumed,  a thorough  and 
complete  cure  was  the  result. 

We  further  observed  that  ulcerative  complications , often 


58 


INDICATIONS  FOR  INJECTION. 


occurring  with  syphilitic  sclerosis,  are  more  tractable  than 
other  symptoms.  After  using  J gr.  of  sublimate,  the  ulcers 
heal,  and  by  the  time  f gr.  to  1 gr.  has  been  used,  cicatriza- 
tion is  complete.  With  the  same  rapidity  ulcera  mollia 
(soft  ulcers)  are  healed,  it  making  no  difference  whether 
they  have  their  seat  on  the  induration  or  in  its  immediate 
neighborhood,  or  whether  they  are  in  other  regions  of  the 
body. 

The  healing  of  the  broad  condylomes  by  injection  of  sub- 
limate is  quicker  and  surer  than  the  cure  of  the  sclerosis,  in 
both  men  and  women,  either  whether  their  seat  be,  as  usual, 
on  the  genital  organs  or  surroundings,  or  near  the  anus,  or 
whether  reaching,  as  a confluent  spreading,  into  the  rectum. 

If  we  consider  the  changes  of  regressive  metamorphosis, 
which  show  themselves  during  the  cure  by  the  sublimate 
injection  on  condylomatous  excrescences,  we  find  that  the 
yellow  crust  covering  them  dries  up,  falls  off  and  the  condy- 
lomatous bases  are  soon  destroyed  by  healing.  Even  the 
pale  red  patches  remaining,  if  the  injection  is  continued, 
change  their  color  to  brown  yellow,  beginning  to  get  paler 
in  the  centre.  The  brown  and  somewhat  darker  pigment  on 
the  periphery  remains  longer,  but  is  without  any  therapeu- 
tical significance  whatever. 

The  amounts  sufficient  in  all  cases  were  from  \ gr.  to  2 gr. 
of  bichloride  mercury  for  the  entire  healing  of  condylomes. 
The  sooner  they  were  treated,  so  much  quicker  the  cure, 
and  vice  versa — showing  that  the  ease  and  quickness  of  cure 
depended  on  the  preceding  duration  of  the  disease.  In  the 
same  ratio  is  the  resistance  against  the  sublimate, — as  to  the 
consistence  and  spreading  of  the  condylomatous  excres- 
cences. The  softer  these  are,  and  the  smaller  the  circum- 
ference they  have,  the  quicker  the  therapeutical  result ; but 


CONDYLOMATA  LATA. 


59 


larger  and  harder  excrescences,  especially  when  ulcerated 
on  their  surface,  require  a more  protracted  treatment. 

The  process  of  cicatrization  has  first  to  be  induced  and 
completely  ended  before  real  involution  can  be  expected. 
Even  here  the  process  of  healing  commences  as  quickly 
with  the  subcutaneous  use  of  the  sublimate  as  in  the  already 
mentioned  cases  of  ulcerative  indurations  of  male  patients. 
We  had  occasion  to  observe  also  how  the  fatty,  dirty-like 
secretion  began  to  dry  up  with  from  four  to  six  sublimate 
injections,  in  doses  of  J gr.  each.  The  condylomatous  ulcers 
begin  to  form  new  cuticle ; the  excrescences  become  flattened 
and  sink  down,  and  perfect  cicatrization  results.  There  is 
also  a difference  of  time  in  healing.  The  most  obstinate  are 
the  broad  excrescences  around  the  anus  and  genital  organs. 
They  are  especially  unyielding  when  their  form  is  pointed 
and  they  reach  into  the  orijicium  ani , or  even  as  far  as  the 
mucous  parts  of  the  anus  and  rectum.  Here  we  find  those 
deep  ulcerated  rows,  produced  by  defecation  and  constant 
tearing.  Healing  here  is  naturally  very  slow. 

(Edematous  swelling  of  the  labia  majora  is  not  a very 
rare  result  from  broad  condylomes,  especially  when  the 
latter  are  ulcerated  and  grouped  together,  giving  rise  to 
fluxions,  hypersemia  and  transudations. 

These  consecutive  swellings  of  the  labia  do  not  require  a 
special  treatment.  On  the  contrary,  the  slender,  long,  indu- 
rated excrescences,  having  their  seat  generally  on  the  inside 
and  on  the  border  of  the  labia  majora,  require  more  than 
ordinary  doses  of  the  bichloride  solution.  We  have  used 
here  2J  gr.,  and  sometimes  even  more  for  a cure. 

And  I must  remark  here,  that  in  some  few  cases  of  con- 
dylomes— and  I have  already  pointed  out  this  with  sclerosis 
— those  excrescences  are  very  unyielding  to  treatment,  and 


60 


INDICATIONS  FOR  INJECTION. 


require  rather  increased  quantities  of  mercury.  Especially 
was  this  the  case  with  those  mucous  papules  which,  instead 
of  being  covered  with  a thin  stratum  of  epidermis  or  epithe- 
leum,  had  a thick  wart-like  epidermis,  so  that  I used  in  my 
lectures  the  special  term  “ condylomata  verrucosa”  * 

A second  species  of  equal  obstinacy,  I gave  the  name 
“ condylomata  mixta  ,”  using  the  same  analogy  existing  be- 
tween them  and  the  so-called  ulcus  mixtum.  With  the  first 
expression  I designate  all  those  papillary  excrescences 
which  originally  have  the  formation  of  broad  condylomes, 
but  instead  of  undergoing  a superficial  fatty  metamorphosis, 
or  an  ulceration,  they  form  on  the  surface  papillary  excres- 
cences. These  are  elevated,  and  easy  of  being  confounded 
with  pointed  condylomes,  and  which,  microscopically  exam- 
ined, show  the  same  spreading  peculiarity  of  the  papillae. 

I shall  pass  on  to  the  local  treatment  of  the  described 
syphilitic  alfections,  namely,  syphilitic  indurations  and  con- 
dylomes, because  I could  not  entirely  lay  aside  local  treat- 
ment with  my  patients  in  the  Charite,  for  the  purpose  of 
experimenting  on  the  pharmaco-dynamic  effects  of  hypoder- 
mic injections  on  broad  condylomes. 

In  constitutional  syphilis,  local  therapeutics  has  to  support 
the  internal  treatment  for  effecting  and  hastening  a cure. 
In  syphilitic  induration  and  ulceration  produced  by  it,  the 
local  treatment  was  quickly  finished — extending  it  to  total 
extirpation,  cutting  the  whole  indurated  surface  off  with 
scissors,  especially  when  seated  on  the  frenulum  glandis , 
prepuce,  or  on  the  skin  of  the  penis,  or  labia  majora  or 
minora. 

Not  with  a view,  as  often  expressed,  to  check  syphilis  in 
that  way,  which  is  contrary  to  the  whole  course  of  the  pro- 
* Warty  condylomes. — Translator’s  Note. 


CONDYLOMATA  LATA. 


61 


gress  of  the  disease,  but  by  extirpation,  I aim  to  lessen  the 
syphilitic  virus  and  check  its  flow  into  the  blood,  regarding 
these  infected  places,  figuratively  speaking,  as  reservoirs 
from  which  the  whole  system  could  be  contaminated. 

In  cases  where  extirpation  is  impracticable,  the  indura- 
tions have  to  be  destroyed  deeply  and  thoroughly,  with  the 
usual  strongest  caustics. 

And  here  let  me  mention  a new  treatment,  not  only  of 
simple,  but  of  obstinate  ulcerations , such  as  have  resisted 
almost  every  kind  of  medication.  I mean  the  use  of  medi- 
cated fluids  by  64  spray  atomization.’ ’ [Vide  my  book, 
46  Clinic  of  Diseases  of  the  Larynx,”  vol.  i.  Inhalation, 
Therapeutics  in  Diseases  of  the  Respiratory  Organs  ; second 
edition,  Berlin,  1865,  p.  157.]  * 

I have  treated  in  this  manner,  in  the  syphilitic  wards  of 
the  Charite  Hospital,  extensive  ulcerations.  The  44  atomiza- 
tion treatment”  begins  with  cold  water  or  medicated  fluid. 
In  many  cases  the  effect  is  a striking  one.  The  ulcerated 
surface  clears ; the  virulent  secretion  entirely  ceases  in  a 
painless  manner,  and  it  seems  that  atomized  spray  of  wTater 
has  a very  stimulating  effect  on  the  ulcer.  Thus  the  tem- 
perature in  sluggish  erosions  may  be  augmented,  while  a 
cooling  off  of  inflamed  ulcers  and  surfaces  may  be  produced. 

It  matters  not  what  the  modus  operandi  may  be  by  which 
the  spray  produces  these  results.  I can  testify  to  its  effi- 
ciency in  a great  number  of  hard,  obstinate  cases,  and  think 
the  treatment  a valuable  addition  to  local  therapeutics. 

Not  only  in  cases  already  mentioned,  did  I see  the  good 
result,  but  also  in  ulcerated  bubos.  Whether  having  an 

* The  author  here  describes  an  apparatus  constructed  according  to 
Bergson.  We,  in  this  country,  may  use  much  the  same  instruments, 
commonly  called  u spray  atomizers.” — Translator’s  Rem. 

6 


62 


INDICATIONS  FOR  INJECTION. 


idiopathic,  sympathetic  or  virulent  origin,  I have  always 
witnessed  highly  satisfactory  results  from  the  treatment  with 
the  atomizer  in  bubos  consequent  upon  inguinal  ulceration. 

I have  no  cases  of  failure  to  record,  in  consequence  of 
ulcerated  bubo,  when  locally  treated  in  this  manner.  The 
only  fatal  cases  occurring  were — one  man,  insane,  who  could 
not  he  induced  to  submit  to  it,  and  another  man,  recently 
dead,  who  had  an  ulceration  of  a bubo  nine  inches  in 
diameter. 

This  result  is  of  greater  importance  yet  for  us,  consider- 
ing that  in  our  wards  from  three  hundred  to  four  hundred 
patients  are  annually  treated.  Some  of  these  cases  had 
been  sent  to  us,  where  the  ulcerations  of  the  bubo  already 
had  reached  such  a grade  of  destruction  that  the  underlying 
muscles  could  be  seen  as  easily  as  in  an  anatomical  prepa- 
ration. We  even  had  cases  where  gangrenous  destruction 
of  enormous  extent,  at  the  bend  of  the  thigh,  was  existing. 

Shortly  after  taking  charge  of  the  syphilitic  wards  of  the 
hospital,  and  before  using  the  spray,  a number  of  fatal 
cases  occurred  in  consequence  of  ulcerations  of  bubos.  One 
died  on  account  of  the  erosion  of  a blood  vessel  rendered 
gangrenous ; another  from  the  enormous  undermining  of  the 
cuticle,  extending  over  the  whole  right  half  of  the  abdomen 
and  around  to  the  spinal  column.  These  cases,  together 
with  the  entire  absence  of  any  like  instances  of  fatality 
since  using  the  spray  atomizer,  are  ample  reasons  for  sus- 
taining this  new  method. 

The  favorable  results  since  that  time  are  the  more 
remarkable,  if  we  take  into  consideration  the  fact,  that  in 
other  and  extensive — and  on  this  account  not  well  circum- 
stanced-charity hospitals,  patients  die  of  hospital  gangrene 
frequently.  This  occurs  even  in  the  smaller  hospitals. 


SWELLING  OF  THE  LYMPHATIC  GLANDS. 


63 


According  to  Dr.  E.  Zeis,  during  the  comparatively  short 
interval  of  three  years  (1864-1867),  of  twenty  patients 
having  bubo,  three  died,  or  fifteen  per  cent.  This  occurred 
at  the  Dresden  Hospital. 

As  to  the  local  treatment  of  broad  condylomes , the  results 
are  more  favorable  than  with  the  before-mentioned  indura- 
tions, because  they  are  more  simple ; and  further,  the  con- 
dylomatous  papillary  excrescences  have  a tendency  to  mole- 
cular destruction  only,  and  very  seldom  produce  deep-seated 
ulcerations. 

I prefer  for  local  treatment  of  broad  condylomes , a paste 
of  zincum  oxydatum , or  chloride  of  sodium  and  calomel. 
This  is  best  of  all  used  remedies. 

Condylomata  mixta  and  condylomata  verrucosa , as  named 
by  me,  are  somewhat  more  difficult  and  complicated,  since 
here  the  hyperplasia  of  the  thick,  hardened  epidermis  is  to 
be  overcome.  In  such  cases  it  is  not  to  be  recommended  to 
use  the  sublimate  injection  to  accomplish  the  final  cure,  but 
resort,  at  your  earliest  convenience , to  extirpation  with  the 
scissors . 

In  condylomata  mixta , I clip  at  first  only  the  point  of  the 
sharpened  excrescences,  on  account  of  their  origin  from  the 
effect  of  the  fluor  vaginalis , and  even  sometimes  of  blen- 
norrhoea  of  Duverney’s  gland.  As  I have  already  stated, 
they  are  more  of  a local  affection,  and  are  not  necessarily 
connected  with  constitutional  syphilis. 

III.  SWELLING  OF  THE  LYMPHATIC  GLANDS. 

Besides  the  already  mentioned  affection,  I think  in  all 
those  processes  denoting  a more  advanced  state  of  venereal 
affections,  which  go  by  the  name  of  secondary  syphilis , ac- 


64 


INDICATIONS  FOR  INJECTION. 


cording  to  Ricord,  there  is  an  undoubted  indication  for  em- 
ployment of  the  subcutaneous  injections  of  sublimate . But 
it  is  necessary  to  make  a suitable  division  between  impor- 
tant and  less  important  complexity  of  symptoms,  and  to 
modify  accordingly  the  indications  as  to  treatment.  It  is 
only  in  those  cases  where  a certain  range  of  characteristic 
symptoms  presents  itself  that  the  injection  ought  to  be 
resorted  to. 

It  is  sometimes  difficult  to  arrive  at  an  accurate  decision, 
especially  in  cases  where,  after  all  syphilitic  symptoms  have 
subsided,  only  indolent  swellings  of  the  lymphatic  glands 
still  remain. 

Here  we  perceive  almost  the  same  appearances  wTe  have 
pointed  out  above  in  sclerosis — that  a complete  cure , with  a 
single  course  of  treatment,  will  hardly  be  effected. 

The  second  important  fact  to  notice  is,  that  after  the  first 
few  injections,  the  swelled  inguinal  glands  and  glands  of  the 
lower  jaw  lose  perceptibly  in  volume  and  hardness;  even 
sometimes  are  reduced  to  half  their  former  size.  But  a sud- 
den stand-still  in  the  progress  of  the  cure  occurs ; the 
glandular  swellings,  to  a certain  point,  cease  to  be  affected 
by  the  sublimate ; and  even  after  the  venereal  virus  is 
eliminated  from  the  system,  undesirable  knots  still  remain. 

The  patients  who  have  watched  with  considerable  pleasure 
the  diminishing  of  the  wreath-like  knots,  become  now  uneasy 
in  mind,  since  these  enlargements  are  in  bad  repute  not 
only  among  non-professional,  but  also  among  professional 
men.  We  physicians  ourselves  feel  suspicious  in  these  un- 
yielding cases,  that  the  still  remaining  glandular  swellings 
are,  to  a certain  degree,  the  store-houses  and  hiding-places 
for  a portion  of  the  syphilitic  virus  or  the  filter  of  the  glan- 


SWELLING  OF  THE  LYMPATHIC  GLANDS. 


65 


dular  tissue.  We  fear  that  from  here  it  will  again  enter  the 
circulation  and  invade  the  organism. 

On  the  other  hand,  we  have  well-authenticated  cases 
where  no  relapse  occurred,  even  with  a remaining  glandular 
tumescence ; and,  therefore,  we  may  hope  that  the  adenitis 
chronica  (chronic  glandular  inflammation),  which  runs  a 
tedious  course,  may  eventuate  in  a perfect  cure. 

In  cases  where  there  are  no  suspicious  complications  we 
may  abstain  from  injections,  and  use  other  medication — as 
baths,  consisting  of  iodides  and  bromides,  conjointly  with 
the  internal  administration  of  iodide  of  potassium,  without 
thus  anticipating  a complete  cure  in  all  cases. 

Such  therapeutics  seem  the  more  justifiable,  because  we 
cannot  ascertain,  with  a certainty,  the  normal  size  of  the 
gland.  I here  mean  the  difference  in  bulk  between  the  ex- 
isting swelled  gland  and  the  gland  originally,  for  we  can 
place  no  reliance  on  the  declarations  of  the  patients,  as  they 
proverbially  deny  the  existence  of  any  glandular  swelling 
previously.  Especially  is  this  the  case  with  the  glandulce 
inguinales  and  submaxillar es9  which  are,  even  in  non- 
syphilitic individuals,  sometimes  considerably  enlarged, 
without  having  occasioned  any  notice. 

Of  greater  significance  are  the  cervical  and  occipital 
glands.  These  are  sometimes  so  small,  in  healthy  and  non- 
scrofulous  subjects,  that  in  examinations  of  the  persons  the 
glands  are  detected  with  difficulty.  If  here  a hyperplasic 
swelling  arises,  it  is  always  suspicious.  It  is  the  same  with 
the  cubital  glands.  The  swelling  here  is,  according  to  my 
view,  always  a pathognomonic  sign  of  syphilis,  notwith- 
standing the  assertion  of  some  authors,  that  this  swelling  is 
always  the  product  of  a mechanical  cause,  especially  hard 
working,  &c.  I have  noticed  in  syphilitic  women,  who 

6* 


66 


INDICATIONS  FOR  INJECTION. 


never  did  any  laborious  work,  a swelling  of  these  glands, 
which  only  subsided  after  an  energetic  anti-syphilitic  treat- 
ment. That  mechanical  causes  may  have  something  to  do 
with  these  swellings,  I have  shown  in  the  statistical  tables 
of  my  former  work  on  the  Charitd  Annals  (vol.  xiv.). 
There  I show  that  the  swelling  of  the  cubital  glands  occurs 
oftener  in  men  who  are  mechanics  than  in  women. 

Lastly,  I may  remark  that,  in  a relatively  great  number 
of  cases  laboring  under  tertiary  syphilis , I have  never  found 
any  swelling  in  the  lymphatic  glands,  more  especially  be- 
cause the  seat  of  this  tardy  affection  is  in  the  deeper,  rather 
than  in  the  superficial  layer  of  tissue  connected  with  these 
named  glands. 

In  the  treatment  of  adenitis , inunction  of  unguentum 
iodinum,  for  softening  the  hyperplastic  glands,  had  but 
little  effect.  I prefer  rather  to  paint  over  the  part  with 
the  tinctura  iodini.  I here  wish  to  urge  caution,  lest  too 
much  local  treatment  by  inunction  excite  the  gland,  and 
thereby  interfere  with  the  process  of  absorption. 


IV.  AFFECTION  OF  THE  MOUTH  AND  PHARYNX. 

Shortly  after  swelling  of  the  mentioned  lymphatic  glands, 
and  sometimes  simultaneously  with  it,  lues  brings  about,  by 
absorption  of  virus,  an  acute  swelling  of  organs  analogous 
to  the  lymphatics , viz. : hyperplasia  of  the  glandular  ele- 
ments and  fibrous  stroma  of  the  tonsils . But  swelling  of 
the  tonsils  is,  as  is  well  known,  a concomitant  phenomenon 
of  other  diseases.  These  glands  enlarge  not  only  with 
scrofulous  persons,  but  a cold  may  produce  a hyperaemic 
swelling  in  healthy  persons.  Irritations,  like  smoking,  too 


AFFECTION  OF  THE  MOUTH  AND  PHARYNX. 


67 


free  an  indulgence  in  strong  drinks,  &c.,  are  likely  to  induce 
this  swelling. 

A differential  diagnosis  can  discover  no  characteristic 
criterion  between  tonsillar  and  syphilitic  affections.  The 
painless  course  of  syphilis,  as  characterized  by  some  au- 
thors, and  the  seemingly  sharp  division  of  the  surroundings, 
especially  at  the  hard  palate,  and  extreme  follicular  affec- 
tions of  the  anterior  part  of  the  mouth  (M.  Cohn)  accompa- 
nying it,  are,  according  to  my  observation,  no  sufficient 
diagnostic  symptom.  Neither  can  I take,  for  a convincing 
criterion,  a singular  bluish  color , changing  to  red ; nor  of  a 
red,  changing  to  a copper-like  color,  as  has  been  much  em- 
phasized by  some  authors,  because  these  divisions  of  color 
are  fraught  with  liability  to  deception,  since  the  most  decep- 
tive of  all  our  senses  is  this  sense  of  color. 

From  the  above  facts,  I find  myself  compelled  never  to 
regard  tonsillar  swellings  as  an  indication  for  treatment  by 
injections. 

Quite  an  importance,  however,  do  anginous  swellings 
have,  when  completing  the  complexity  of  other  suspicious 
symptoms,  which,  as  single  factors,  may  not  be  charac- 
teristic, but  whose  combination  may  have  a great  importance 
for  the  diagnosis  of  syphilis.  I (Jo  not  mean  here  those 
cases  where  syphilis  has  already  been  developed,  nor  where 
residues  remained,  leaving  no  doubt  in  diagnosis ; but  such 
cases  where  sure  and  decisive  symptoms  are  absent,  and 
others  have  to  be  taken  for  diagnosis. 

If  in  such  persons  not  only  the  submaxillary  glands  are 
swollen,  which  may  be  the  case  in  scrofulous  amygdalitis, 
but  if  the  cervical  glands  also  have  been  drawn  into  the 
hyperplasic  process,  or  even  the  submental  glands , and  if 
there  should  be  a suspicious  and  unexplainable  dejluvium 


68 


INDICATIONS  FOR  INJECTION. 


capillorum  (loss  of  hair),  if  the  pharynx  or  tonsils  have  on 
the  mucous  parts  white,  grayish  patches  or  erosions  (more 
fully  to  be  explained  by  and  by),  I do  not  hesitate  to  order 
the  injection,  even  if  syphilitic  appearances  have  vanished 
from  the  genitals. 

The  effect  of  the  remedy  is,  in  such  cases,  a very  rapid 
cure — using  only  from  J gr.  to  f gr.  of  the  sublimate. 

Not  only  is  the  cause  of  hyperplasia  of  the  tonsils  difficult 
to  diagnosticate,  but  so  is  acute  inflammation,  arising  from 
fresh  ulceration . Real  syphilitic  ulcers  are  very  seldom  to 
be  found  in  the  first  stages  of  the  disease  of  which  we  treat 
here  entirely,  but  they  belong  to  a later  period.  I have 
seen  in  some  cases  ulcerations  whose  character  did  not  seem 
syphilitic,  even  if  the  indirect  cause  may  have  originated 
in  lues . 

The  ulcerative  process  hereby  given  is  rather  mechanical, 
but  is  according  to  my  observation.  In  the  interstitial  tis- 
sues a specific  inflammation  commences;  with  the  rising 
inflammation  a hyperplasic  process  on  the  one  side,  and  an 
exudative  process  on  the  other,  begins — the  effect  being 
somewhat  identical  on  the  open  and  on  the  closed  follicles. 

These  two  categories  of  glands  are  excited  by  compres- 
sion, as  shown  above,  bringing  about  ulcerations  thus  : the 
follicles,  which  lead  in  an  open  way  to  the  mucous  mem- 
brane, are  undergoing,  by  pressure  and  excitement,  a round 
follicular  ulceration,  while  the  closed  sebaceous  glands  form 
a confined  submucous  abscess,  which  opens  slowly,  and  then 
forms  a circular  ulcer,  spreading  rather  deeply  into  the 
tissues.  The  interstitial  tissue  in  these  parts  changes  by 
inflammatory  hyperemia,  and  very  often  ulcerates  on  ac- 
count of  the  hyperplasia  and  exudation.  This  process  does 
not  form  a round,  but  a diffused,  infiltrated,  irregular  ulcer. 


AFFECTION  OF  THE  MOUTH  AND  PHARYNX. 


69 


Even  on  other  parts  of  the  pharynx,  where  the  glandulce 
acinosce  predominate  over  the  sebaceous  glands , the  same 
analogous  process  may  take  place. 

The  mucous  glands,  drawn  into  affection  by  sympathy 
with  the  surrounding  swelled  and  inflamed  interstitial  tissue, 
are  animated  to  a greater  secretion,  and  very  soon  not  only 
the  quantity,  but  the  quality  of  the  secretion  undergoes 
important  changes.  The  already  formed  ingredients  prevail 
over  the  intercellular  fluid,  which  becomes  more  consistent, 
and  by  its  final  inspissation  closes  its  own  outlet.  In  time, 
a u retention  cyst  ” is  formed  by  the  gathering  of  thick  mu- 
cous, rising  above  its  surroundings.  After  a longer  or 
shorter  time,  the  resistant  cellular  contents,  by  a process  of 
softening,  go  into  a retrogressive  metamorphosis,  in  conse- 
quence of  which  an  abscess  breaks,  and  presents  itself  as  a 
small  follicular  ulcer. 

This  ulceration  may  enlarge  in  two  ways : first,  on  the 
arches  of  the  palate  by  mechanical  effects,  produced  by  mas- 
tication and  deglutition ; secondly,  the  irregular  histological 
condition  of  the  affected  tissue  may  take  on  the  ulcerative 
process,  enlarging,  as  has  often  been  noticed,  with  the  velum 
pendulum  palati . Here  is  a singular  circumstance  existing. 
Between  the  folds  of  the  anterior  and  posterior  mucous  sur- 
faces there  is  situated  a loose  tissue,  seeming  to  have  but 
few  vessels  of  absorption.  If  now  an  abundant  exudation 
around  the  follicles  is  formed,  as  it  sometimes  happens,  they 
will  very  easily  become  ulcerated  on  account  of  the  lessened 
absorption.  In  this  manner  I have  seen,  in  a few  instances, 
ulcerations  and  even  perforations  of  the  described  region — 
in  persons,  too,  who  have  never  been  syphilitic,  or  when 
syphilis  had  been  eradicated.  Such  ulcers  heal,  as  is  well 


70 


INDICATIONS  FOR  INJECTION. 


understood,  after  an  ordinary  local  treatment,  especially  by 
pencilling  with  argentum  nitricum. 

Repeated  observations,  that  especially  scrofulous  ulcera- 
tions, producing  loss  of  the  substance  forming  the  pharynx, 
have  been  taken  by  the  majority  of  physicians  as  syphilitic, 
and  even  as  tuberculous,  induce  me,  from  a variety  of  cases, 
to  select  the  following  two.  In  both,  later  arising  scrofulosis 
showed  that  a scrofulous  diathesis  was  the  intermediate  cause 
of  the  ulcers,  complicated  with  a diphtheretic  affection  : 

Case  1. — Marie  B.,  from  G.,  fifteen  years  old,  descends  from  a family 
where  the  father  died  with  heart  disease ; mother  and  sisters  are  in 
good  health.  Patient  had  in  her  childhood  measles  and  scarletina. 
When  fourteen  years  old  she  was  taken  sick  (I  quote  here  the  words  of 
the  attending  physician,  Dr.  Strahler,  who  had  the  kindness  to  send  me 
the  patient),  in  winter,  probably  from  a taking  of  cold.  She  suffered 
with  scrofulous  periostitis  of  the  left  tibia,  and  used  cod  liver  oil.  In 
the  spring  of  1866,  she  was  taken  with  a catarrhal  angina  and  laryn- 
gitis. The  generally  used  anti-catarrhal  treatment  had  no  perceptible 
effect,  and  resorted  again  to  the  anti-scrofulous  treatment.  The  patient 
took  salt-water  baths,  drank  mineral  waters  with  whey,  and  later,  cod 
liver  oil,  and  was  pencilled  every  other  day  with  a middle-strong  solu- 
tion of  argentum  nitras)  changing  from  better  to  worse,  and  vice  versa. 
Her  condition  became  more  precarious  after  a voyage  to  Berlin,  where 
a diphtheretic  affection  set  in.  Examination  revealed  a defect  on  the 
anterior  border  of  the  epiglottis,  and  ulceration  on  the  mucosa  of  the 
arytenoid  cartilages.  Bathing,  the  use  of  u Adelheidsquelle  ” (a  min- 
eral spring  in  Germany),  and  inhalations  were  employed.  The  result, 
in  a single  fortnight,  was  a surprising  one.  Deglutition  was  less  pain- 
ful ; appetite  increasing ; nutrition  and  strength  visibly  progressing. 
Unluckily,  the  cholera,  which  broke  out  in  the  house  of  the  patient, 
retarded  further  progress.  Patient  was  taken  with  diarrhoea,  and  her 
mother  took  her  into  the  country.  The  treatment  could  not  be  con- 
tinued, consequently  the  ailments  of  the  throat  increased  and  a 
hoarseness  followed. 

I saw  the  patient  in  October,  1866;  found  her  greatly  emaciated; 
muscular  development  slight;  stooping  gait;  pale,  greenish-yellow 
complexion,  and  of  a general  anaemic  appearance.  While  telling  me 


AFFECTION  OF  THE  MOUTH  AND  PHARYNX. 


71 


her  history,  she  was  frequently  interrupted  by  coughing ; mostly  com- 
plained of  pain  in  deglutition,  dyspnoea,  cough  and  hoarseness,  with  a 
good  deal  of  11  hawking,”  and  an  expectoration  of  a tenacious  sputum 
filled  with  air-bubbles.  During  eating,  a portion  of  her  food  would 
pass  through  her  nose. 

Examination  revealed  copious  ulceration  of  the  pharynx,  and  especially  a 
part  of  the  arcus  palati-pharyngeus  and  velum  was  so  united  with  the  poste- 
rior roof  of  the  palate  that  only  a small  orifice  remained  for  communication 
with  the  pars  nasalis  and  oralis.  The  uvula  was,  through  ulceration,  nearly 
destroyed.  At  the  left  tonsil  there  was  situated  a great  ulcer,  covered  with 
unhealthy  pus,  extending  to  the  posterior  part  of  the  palate  roof  and  reaching 
deeper  down  into  the  larynx.  Laryngoscopic  examination  revealed  a dis- 
charging ulcer  on  the  free  border  of  the  epiglottis,  which  had  already  destroyed 
a large  portion  of  it.  The  ligamenta  aryepiglottica,  especially  the  left,  was 
swelled,  ajid  seemed  to  be  eroded  on  its  surface.  The  vesicles  of  Galen  were 
covered  with  pus.  The  arytenoid  cartilages  were  swollen,  and  showed,  par- 
ticularly the  left,  an  oval  purulent  ulcer , with  sharp  borders  on  the  one  side 
and  flat  edges  on  the  other.  The  vocal  cords  could  not  be  thoroughly  exam- 
ined, on  account  of  the  swollen  thyroid  cartilages.  Shortly  before  the  patient 
came  under  my  care,  she  was  examined  by  two  other  specialists , one  of  whom 
pronounced,  as  reported,  her  case  incurable  tuberculosis  ; the  other  seemed  to 
think  her  syphilitically  affected.  I at  once  pronounced  it  to  be  a case  of  sim- 
ple scrofulosis , amenable  to  treatment,  and  proceeded. 

Besides  the  already  prescribed  anti-scrofulous  medication,  I treated 
the  ulcer  on  the  pharynx  and  larynx  partly  with  argentum  nitricum  and 
partly  with  iodized  glycerin.  The  patient  was  completely  restored  to 
health  in  a few  months.  That  the  cure  was  a lasting  one,  a letter 
from  my  esteemed  colleague,  Dr.  Strahler,  confirms. 

Case  2.* — Miss  S.  A.,  seventeen  years  old,  of  healthy  parents,  has 
generally  been  healthy,  with  the  exception  of  an  eruption  on  the  scalp, 
lasting  from  earliest  childhood  up  to  her  twelfth  year,  and  which,  as 
reported,  disappeared  regularly  in  summer  and  returned  again  in  win- 
ter. According  to  description,  this  eruption  seemed  to  have  the  char- 


* The  most  important  cases  in  my  practice  of  former  years  have  been 
mostly  published  in  my  already  mentioned  work  on  Injections  of  Subli- 
mate. The  material  of  the  present  work  I have  taken  from  recent  ex- 
perience, and  hence  have  not  taken  cases  from  my  researches  on 
relapses. 


72 


INDICATIONS  EOR  INJECTION. 


acter  of  eczema  impetiginosum.  The  treatment  was  only  a local  one.  In 
the  fourteenth  year  the  catamenia  commenced,  but  scantily,  and  have 
continued  irregularly  till  the  present. 

In  August,  1868,  she  was  attacked,  as  it  seems,  with  angina  tonsil- 
laris, accompanied  with  much  pain,  especially  in  deglutition.  After  a 
few  days  an  abscess  was  formed,  which  having  opened,  a great  deal  of 
pus,  mixed  with  blood,  was  discharged.  After  a few  weeks,  a relapse 
occurred — a new  abscess  was  formed,  also  discharging  blood  and  pus. 
Notwithstanding  the  use  of  gargarisms,  the  condition  did  not  improve; 
on  the  contrary,  deglutition  was  still  more  painful,  and  the  food  was 
regurgitated  through  the  nasal  passages. 

The  family  physician,  Dr.  Stubenrauch,  physician  to  the  royal  court, 
transferred  the  patient  to  me.  He  said  that  he  had  only  seen  such 
large  ulcerations  in  this  region  exclusively  with  syphilitics,  and  there- 
fore made  a thorough  examination  of  the  patient  and  family,  but  failed 
to  get  any  warrantable,  proof  for  his  suspicion. 

The  patient  was  of  medium  size,  well  built,  pale,  and  face  somewhat 
oedematous.  Exploration  of  the  chest  did  not  present  anything  abnor- 
mal. The  ceryical  and  submaxillary  glands  were  but  little  swelled. 
The  inspection  of  the  pharynx  revealed  a great  ulcer , reaching  deeply  into  the 
submucous  tissue , of  the  size  of  a Prussian  thaler , which  seemed  to  start  from 
the  left  anterior  roof  of  the  palate , having  already  destroyed  both  tonsils.  The 
borders  of  the  ulceration  were  livid  and  swelled , and  somewhat  undermined . 
The  pus  was  of  a dirty  gray  color , firmly  adherent  and  of  a thick  consistency. 
Laryngoscopic  examination  shoivcd  a hypersemia  and  slight  swelling  of  the 
mucous  membrane  of  the  larynx , without  loss  of  substance. 

Thinking  that  the  basis  of  this  disease  was  only  scrofulous,  I recom- 
mended internal  anti-scrofulous  medication  and  local  pencilling  with 
argentum  nitras.  After  the  lapse  of  some  months,  the  patient  was  com- 
pletely restored  to  health. 

Exploration  now  showed  a star-like  cicatrix , reaching  doivn  to  the  vertebrse 
of  the  neck , which  resulted  in  gluing  the  right  roof  of  the  palate  with  the  an- 
terior wall  of  the  mouth.  Of  the  left  roof  a small  part  remained.  The  ton- 
sils were  wanting  entirely.  A small  erosion  of  the  nose  indicated  an  exist- 
ence of  ozsena  scrofulosa , now  already  healed. 


The  same  precaution  is  necessary  for  that  affection  of  the 
fauces , resembling  sharp-bordered , grayish  ivhite,  milky 
patches , that  French  authors  have  named  “ plaques  opalines / 


AFFECTION  OF  THE  MOUTH  AND  PHARYNX. 


73 


and  recent  German  syphilograplis , according  to  Sigmund , 
psoriasis  oris . 

The  latter  definition  seems  to  me  characteristic,  regarding 
the  pathological  and  histological  processes,  which  are  the 
same  as  in  psoriasis  vulgaris . 

If  these  plaques  opalines , as  is  sometimes  the  case  in  the 
early  beginning,  appear  isolated,  it  is  better  always  to  await 
their. further  course,  and  treat  them  meanwhile  on  the  ex- 
pectant plan — even  if  the  grayish  white  patches,  encircled 
by  a red  border,  commence  to  elevate , and  the  epithelial 
stratum,  seemingly  adipose,  appears  to  thicken. 

Only  then  do  I commence  therapeutical  treatment,  when 
changes  of  texture  occur  by  which  the  plaques  opalines 
change  to  plaques  ulcereuses , as  one  may  call  them.  They 
are  thus  characterized : after  the  removal  of  the  fatty 
epithelium,  the  eroded  hyperplastic  papules'  appear  flesh- 
colored,  and  around  the  milky  epithelium  molecular  detritus 
is  formed.  We  have  a yet  surer  ground  for  diagnosis,  since, 
besides  the  mentioned  processes,  a condylomatous  wreath- 
like excrescence  of  infiltrated  papillary  bodies  exists , arising 
on  those  places  ivhich  have  a locality  favoring  their  forma- 
tion— as , for  instance , the  back  part  of  the  tongue , hard 
palate , <fc. 

Sometimes  these  affections  of  the  mucous  membrane 
evince  the  most  marked  characteristics  during  advanced 
ulceration,  which  characteristics  are  on  places  not  easy  of 
access  for  examination.  I mean  those  pits  called  by  me 
fovece  tonsillares , in  which  the  tonsils  are  embedded . The 
roofs  of  these  pits  are  formed  by  the  posterior  surface  of 
the  arcus  palato-glossus  and  arcus  palato-pharyngeus. 

By  deglutition  and  phonation,  attrition  is  sometimes  pro- 
duced on  these  mentioned  roofs,  and  in  this  manner  excoria - 
7 


74 


INDICATIONS  FOR  INJECTION. 


tions  and  deeper  ulcerations  are  caused.  Especially  is  this 
the  case  -when  these  parts  are  swollen  by  the  syphilitic  pro- 
cess, as  they  irritate  themselves. 

These  symptoms  are  very  obstinate,  and  remain  quite  a 
time,  even  after  all  syphilitic  appearances  have  vanished  and 
the  venereal  disease  itself  has  been  eradicated.  Such  pa- 
tients complain  of  pains  in  the  throat,  which  increase  with 
speaking,  mastication  and  respiration,  and  particularly  with 
gaping.  The  sense  localizing  these  pains  is  rather  vague  in 
the  pharynx  and  larynx,  and  for  this  reason  patients  are 
apt  to  designate  wrong  regions  as  the  seat  of  their  com- 
plaints, and  thus  are  very  liable  to  mislead  a physician  not 
well  versed  in  laryngoscopy.  Such  a physician,  according 
to  his  examination  of  the  pharynx,  finds  no  affection  ex- 
plaining the  complaints,  and,  from  want  of  diagnosis,  is 
obliged  to  declare  the  patient  suffering  from  syphilis. 

According  to  my  experience,  those  tonsillar  pits  and 
their  diseased  formations  may  be  seen  in  a double  manner : 
first , with  a small  laryngoscopic  mirror , held  sideiuise ; 
secondly , by  using  either  the  handle  of  the  mirror  or  the 
finger  to  push  the  anterior  roof  of  the  p>alate  aside  and  back- 
wards. If  this  manipulation  should  induce  an  effort  to 
vomit,  so  much  the  better,  because  the  looked-for  places  are 
seen  the  more  clearly. 

The  ulcerations  on  the  visible  parts  of  the  tonsils  and 
pharynx  may  either  be  a residue  of  a syphilitic  affection,  or 
may  be  only  an  ailment  of  a local  nature.  The  therapeutics 
in  either  case  are  not  identical.  In  the  first  case,  I use  im- 
mediately injections  hypodermically,  with  pencillings  of  the 
parts  with  argentum  nitricum  ; in  the  other  case,  the  latter 
is  sufficient.  But  the  application  to  the  hidden  regions  is 
more  difficult.  Therefore,  I recommend  the  physician  to 


AFFECTION  OF  THE  MOUTH  AND  PHARYNX. 


75 


hold  the  anterior  roof  of  the  palate  back,  and  with  the  right 
hand  apply  the  pencil  of  argentum  nitricum,  care  being 
taken  that  it  does  not  break  or  crumble.  It  is  the  safer 
and  better  way  to  use  the  porte  caustic  of  Lallemand. 

According  to  my  experience,  the  cavum  pharyngo-nasale 
has  a like  diagnostic  and  nosologic  importance  to  the  cavum 
pharyngo-orale.  In  this  region  we  find  the  same  histological 
elements  as  there,  and  that  they  are  more  subject  to  change, 
particularly  on  account  of  their  histological  and  anatomical 
condition.  The  peculiar  configuration  and  difficulty  of 
access  is  a more  favorable  condition  for  unimpeded  destruc- 
tion of  tissue  than  exists  in  the  deeper  part  of  the  lower 
pharynx.  We  notice  here  that  a tissue  is  predominant, 
which,  according  to  Hiss  and  Luschka  (two  eminent  German 
anatomists),  is  named  adenoid  tissue , having  innumera- 
ble folds  and  chinks,  like  a ravine.  Here  the  swelling  of 
the  extensive  glandulce  mucosce , analogous  to  the  solitary 
glands  of  the  intestines,  very  often  and  easily  gives  rise  to 
erosion,  which  is  seldom  detected,  because  so  hidden  from 
observation.  Here  swelling  of  the  fibro  cartilaginous  sub- 
stance of  the  tuba  eustachii , covered  by  mucous  membrane , 
easily  produces  functional  derangement  of  the  auditory 
nerve , like  hardness  of  hearing , tinnitus  aurium , <?. 

Moreover,  there  is  in  those  hidden  regions  (thoroughly 
explored  by  but  few  anatomists)  a glandular , fold-like , ele- 
vated mass , in  some  individuals  in  the  neighborhood  of  the 
septum  narium.  This  mass  I wish  to  name  tonsilla  pha - 
ryngea , in  opposition  to  Luschka,  who  designates  the  greater 
portion  of  the  mucous  membrane  of  the  roof  and  posterior 
part  of  the  pars  nasalis  with  this  name.  In  not  very  rare 
instances,  I have  here  detected  ulcerations  in  patients  hav- 
ing  syphilis,  and  mostly  in  a comparatively  early  stage  of 


76 


INDICATIONS  FOR  INJECTION. 


the  disease.  I often  took  occasion  to  demonstrate  such 
affections  in  my  laryngoscopic  and  syphilitic  lectures  to  my 
students,  aided  by  the  rhinoscope. 

Such  affections  on  that  locality  have  a greater  importance, 
since  their  existence  is  not  easily  produced  by  a simple  cold. 
The  cold  atmospheric  air  enters  not  directly,  as  into  the 
cavum  pharyngo-orale , but  it  first  passes  by  the  nostrils 
through  the  choance , and  gets  to  this  point  in  a warmed 
state.  Care  has  to  be  taken  not  to  confound  these  ulcera- 
tions with  those  follicular  affections  occurring  here  very 
often  without  any  visible  lesions,  and  which  are  produced, 
according  to  Luschka,  either  by  fatty  degeneration  of  the 
cells  or  colloid  destruction.  With  the  destruction  of  the 
substance  of  glands,  erosions  will  appear  on  the  surface. 

Case  3. — S.,  twenty-seven  years  old,  from  healthy  parents,  suffered, 
when  three  years  old,  from  a swelling  of  the  neck,  which  gave  rise  to 
spontaneous  abscesses.  When  ten  years  old,  he  had  the  misfortune  to 
cut  with  glass  the  brachial  artery,  so  that  ligation  of  the  arteria  ax- 
illaris was  necessary.  Slight  atrophy  of  the  left  arm,  still  existing,  oc- 
curred as  a consequence.  In  the  summer  of  1864,  patient  was  venereally 
affected  for  the  first  time.  The  ulceration  on  the  penis  was  diagnosed 
in  the  beginning  as  a soft  chancre,  and  treated  accordingly.  Only 
after  six  weeks’  time  was  the  physician  convinced  that  the  ulceration 
had  the  character  of  a hard  chancre.  The  treatment  then  consisted  in 
a combination  of  decoctum  Zittmanni  with  pilulae  Dzondi.  This  treat- 
ment, with  a run  of  ague,  weakened  the  patient  considerably. 

A relapse  of  syphilis,  occurring  a short  time  subsequently,  was  again 
treated  with  a “ sarsaparilla  sweat  cure”  and  Berg’s  pills;  but  still 
there  remained  an  unyielding  induration  on  the  penis,  which  did  not 
subside. 

In  the  winter  of  the  same  year,  a papulous  exanthem  was  found  upon 
the  chest,  beside  psoriasis  palmar  is,  with  affections  of  the  throat. 

Entering  a Berlin  clinic,  the  patient  again  used  decoctum  Zittmanni 
and  inunctions  for  five  weeks,  besides  using  for  a time  a solution  of 
iodide  of  potassium. 


AFFECTION  OF  THE  MOUTH  AND  PHARYNX. 


77 


After  being  discharged  “ cured”  from  the  hospital,  in  four  days  (!) 
psoriasis  palmar  is  showed  itself  again,  together  with  the  throat  affection. 
Iodide  of  potassium  was  again  used,  but  being  insufficient,  he  was  again 
obliged  to  undergo  the  inunction  treatment  for  about  seven  weeks. 
For  after-treatment  he  was  sent  to  Kreuznach,  and  took  forty-two 
baths. 

In  consequence  of  this  treatment,  a stand-still  of  the  syphilitic  dis- 
ease occurred,  and  the  patient  went  through  the  Bohemian  campaign 
of  1866. 

A short  time  afterwards,  there  appeared  again  a maculous  syphiloid, 
for  which  he  used,  with  good  result,  iodide  of  potassium. 

In  the  summer  of  1867,  he  went  to  Aachen  for  baths.  Nevertheless, 
he  suffered  again  in  autumn  with  syphilitic  throat  affection,  for  which 
inunction  for  three  weeks  was  again  used. 

In  February  he  came  to  me  for  treatment  on  account  of  his  throat. 
He  was  emaciated ; had  an  ash-colored  complexion ; muscles  well 
developed. 

Examination  of  the  pharynx  showed  superficial  ulceration  at  the  soft  palate 
— at  the  uvula  and  surroundings.  There  was  also  a deep  loss  of  substance 
of  the  size  of  a bean  on  the  side  and  posterior  surface  of  the  left  tonsil , which 
reached  somewhat  on  to  the  posterior  roof  of  the  palate  ; but  especially  was 
there  ulceration , of  the  size  of  a penny , on  the  convex  surface  of  the  soft 
palate , which  I could  only  detect , naturally  enough , with  the  rhinoscope.  All 
the  ulcers  had  a clearly  syphilitic  character. 

On  account  of  swelling  of  the  cervical  and  submaxillary  glands,  swell- 
ing of  the  glands  of  the  tongue,  and  erosions  and  infiltrations  of  the 
latter,  I thought  an  anti-syphilitic  treatment  indicated,  since  the  other 
medications  had  proved  useless.  I commenced  with  the  subcutaneous 
method,  which  effected  a complete  cure  with  twenty  injections  (2J  gr.). 
For  after-treatment  we  sent  him  to  Kreuznach,  and  later  to  Ostende. 

The  patient  has  since  been  free  from  syphilitic  trouble  ; but  after  the 
lapse  of  four  months,  those  singular  follicular  affections,  described 
above  by  me,  commenced  in  different  regions  of  the  pharynx.  They, 
however,  yielded  to  local  treatment  entirely.  They  first  appeared  mostly 
under  the  form  of  a kernel,  having  the  size  of  a pin’s  head,  and  being  of 
a pale  yellow  color.  They  were  embedded  in  the  mucous  tissue,  and 
resembled  small  metamorphosed,  fatty  pouches,  the  contents  of  which 
soon  became  purulent,  and  breaking  through  the  mucous  tissue,  the 
small  ulcers  were  open,  but  were  tractable  to  the  cautery.  On  the 

7* 


78 


INDICATIONS  FOR  INJECTION. 


convex  surface  of  the  velum,  by  the  confluence  of  follicular  ulcerations, 
larger  erosions  were  formed,  which  also  disappeared  with  cauteri- 
zation. 

In  consequence  of  collateral  fluxion  and  exudation,  a swelling  of  the 
mucous  membrane  and  the  subjacent  tissue  followed,  causing  a stenosis 
of  the  already  narrow  cavum  pharyngo-nasale , and  some  trouble  to  the 
patient. 

Now,  not  only  my  experience  shows  that  these  affections 
of  the  pharynx  are  not  of  a syphilitic  nature,  because  I 
have  very  often  seen  such  ulcerations  in  persons  who  never 
have  had  syphilis,  but  in  this  special  case  all  other  venereal 
symptoms  were  absent,  as  shown  by  the  previously  described 
specific  ulceration  of  the  pharynx  not  returning ; and  lastly, 
another  evidence  of  the  non-syphilitic  nature  is  that  the 
pencilled  places  always  remained  in  a healed  condition. 
New  ulcerations  always  proceeded  from  other  follicles. 

I take  this  occasion  here  to  direct  attention  to  two  inter- 
esting processes,  which  I think  have  never  been  mentioned. 
First,  I saw  in  some  cases,  on  the  free  borders  of  the  palate 
roof  and  even  on  the  soft  palate , and  further,  on  the  tonsils 
and  uvula , condylomatous  granulations , which  distinguish 
themselves  in  size  and  height  from  the  commonly  here-occur- 
ring vegetations , fully  resembling  those  broad  verrucous 
condylomes  which  were  considered  as  an  exclusive  preroga- 
tive of  the  labia  majora . They  resisted  in  the  same  manner 
all  attempts  at  cauterization,  and  I had  to  extirpate  them 
with  the  scissors. 

Scarcely  a yet  more  singular  appearance  was  there  in 
some  cases,  in  which  I had  already  used  injections  with 
good  result.  The  above  described  obstinate  papillary  granula- 
tions commenced  to  form  in  the  region  of  the  pharynx,  and 
so  extensively,  particularly  on  the  mucous  membrane,  that 


AFFECTION  OF  THE  MOUTH  AND  PHARYNX. 


79 


the  greatest  part  of  the  anterior  roof  of  the  palate  and  uvula 
was  literally  covered  ivith  those  grayish-white  excrescences . 

Very  easily  we  could  have  been  misled,  and  taken  those 
appearances  for  a sort  of  an  after  disease,  consequent  upon 
the  use  of  the  sublimate,  if  those  prolific  cellular  granula- 
tions had  not  showed  most  clearly  the  papillary  and  condy- 
lomatous  type.  On  account  of  having  derived  the  first 
time  no  result  on  the  vegetations , by  the  continuation  of  the 
injection , I resolved  to  try  other  medication,  especially 
the  “ sarsaparilla  sweat  cure”  and  inunction.  But  this 
mode  of  treatment  also  was  without  efficacy,  and  I returned 
finally  again , in  these  desperate  cases , to  injections , which 
brought  about  a complete  cure. 

Recently  I have  observed  several  cases  in  which , during 
and  after  an  anti-syphilitic  treatment , the  mentioned  excres- 
cences of  the  pharynx  were  formed  in  a similarly  original 
way;  also,  these  cases  yielded  to  the  subcutaneous  injec- 
tions with  such  complete  result  that  we  may  prescribe  it 
here  as  the  ultimum  refugium.  The  importance  of  the 
mentioned  cases  will  permit  and  justify  me  in  reporting  a 
few  more  of  this  peculiar  class. 

Case  4. — Caroline  K.,  twenty-six  years  old  ; well  built ; for  the  first 
time  infected  with  syphilis,  and  received  on  the  llth  of  February,  1861, 
into  Charite  Hospital.  Besides  greatly  ulcerated  condylomes  on  the 
labia  majora  and  right  buttock,  both  tonsils,  the  palate  roofs  and  uvula 
showed  large  white-grayish  papules,  resembling  a comb,  and  having 
the  appearance  of  condylomata  mixta,  as  described  by  me  ; i.  e.,  pointed 
warts  like  the  comb  of  a cock,  with  an  infiltrated,  broad  papillary  base. 
These  excrescences  nearly  filled  the  space  in  the  mentioned  regions  of  the  pha- 
rynx, hindering  their  movement  so  that  the  voice  took  a nasal  sound , as  in 
paralysis  of  the  velum. 

Subcutaneous  injections,  in  suitable  doses,  to  the  amount  of  2 gr.  of 
sublimate,  with  internal  administration  of  3 dr.  of  iodide  of  potassium, 
and  pencilling  parts  with  argentum  nitras,  produced  a complete  cure. 


80 


INDICATIONS  FOR  INJECTION. 


Case  5. — Caroline  F.,  twenty  years  old ; for  the  first  time  syphiliti- 
cally  infected  ; was  received  into  my  ward  January  17,  1867.  Examin- 
ation revealed  broad,  button-shaped  condylomes  on  the  labia  majora, 
and  a large,  pus-producing,  ulcerated,  flat  swelling,  of  the  size  of  a 
dollar,  on  one  of  the  hypertrophied  folds  in  the  vicinity  of  the  anus. 

On  the  tonsils,  the  anterior  roofs  of  the  palate  and  uvula,  large,  per- 
manent papules  were  seated,  forming  a comb-like  elevation  resembling 
in  appearance  my  description  of  condylomata  mixta.  They  evinced 
much  resistance  to  treatment.  After  an  injection  of  2 gr.  of  sublimate, 
the  genital  erosions  disappeared,  leaving  behind  the  hyperplasia  pro- 
ducts in  the  pharynx,  which  required  the  addition  of  1|  gr.  of  the  sub- 
limate to  effect  their  destruction. 

Case  6. — Emily  S.,  twenty-three  years  old ; already  three  times  in 
our  hospital  for  syphilis,  besides  also  for  some  blennorhagic  troubles; 
was  again  received  March  1 7,  1868,  into  the  Charite.  The  following 
was  her  condition:  soft  chancre  at  the  vaginal  opening;  tonsils 
markedly  hypertrophied  and  somewhat  eroded ; inguinal  glands 
swollen. 

The  patient  was  subjected  to  local  treatment,  during  which  time  gray  - 
whitish  condylomatous  granulations  were  formed  on  the  tonsils . Notwith- 
standing our  subcutaneous  injections,  these  tonsillar  granulations 
increased  so  much  that  they  were,  after  fourteen  injections  (t.  e.,  after 
the  equivalent  to  2 gr.  of  sublimate  had  been  used),  the  size  of  a pea, 
and  covered  much  of  the  right  tonsil.  At  the  same  time,  the  lower  por- 
tion of  the  arcus  palato-glossus  was  changed  into  a comb-like  elevation, 
last-shaped,  four  lines  broad  and  one-third  of  an  inch  long,  with  a firm 
texture  and  a whitish-gray  color.  Only  after  the  further  use  again  of 
2 gr.  sublimate  and  repeated  cauterizations,  was  complete  cure  es- 
tablished. 

Case  7. — Marie  S.,  nineteen  years  old;  was  already  in  our  hospital, 
February  29,  1868,  with  an  indurated  ulcer,  accompanied  with  a macu- 
lous  syphiloid.  Being  treated  by  injections,  she  was  discharged  seem- 
ingly cured. 

Three  and  a half  months  afterwards,  being  sick,  she  returned,  and  we 
found  again  the  maculous  syphiloid,  besides  an  extensively  ulcerated 
broad  condylome  on  the  labia  majora.  The  patient  besought  us  to  use 
with  her  inunction,  and  we  prescribed  of  unguentum  hydrag.  cinereum 
3j  daily.  After  having  already  used  of  this  gxij,  and  the  genital  affec- 


AFFECTION  OF  THE  MOUTH  AND  PHARYNX. 


81 


tion  being  but  little  ameliorated,  we  saw,  to  our  surprise,  the  appear- 
ance on  the  tonsils,  palate  roofs  and  uvula,  of  grayish-white  papules  of 
the  size  of  a pea.  The  papillae  of  the  roots  of  the  tongue  were  swelled, 
and  also  the  vocal  cords  reddened  and  eroded  in  the  middle  with  the 
epithelium  colored  grayish-white. 

After  a still  further  using  of  the  ung.  hyd.  cin.  gxiij  additional,  to- 
gether with  the  use  of  iodide  of  potassium,  the  hyperplassia  of  the  pha- 
rynx did  not  disappear,  but,  on  the  contrary,  enlarged. 

With  the  consent  of  the  patient,  we  began  again  the  hypodermic 
injections,  in  doses  of  gr .per  diem.  On  the  second  day  after,  a dose 
of  f gr.  Slight  symptoms  of  mercurial  intoxication,  in  the  form  of 
gastro-enteritis,  connected  with  great  prostration,  followed.  They 
soon  subsided,  and  after  a few  days  we  could  use  J gr.  doses.  After 
having  again  used  2 gr.,  instead  of  the  described  papules,  the  tonsils 
were  covered  with  small  milky  epithelium,  which  subsided  after  ten 
more  injections  of  gr.  each  of  sublimate.  The  patient  looked,  after 
the  cure  was  completed,  rather  pale  and  anaemic,  but  felt  entirely  well, 
and  all  the  functions  were  regular. 

Case  8. — C.  N.,  a student,  twenty-one  years  old,  was  taken,  accord- 
ing to  his  statement,  a short  time  after  incubation,  with  a chancre,  soft 
in  the  incipiency,  but  which  was  said  to  be  indurated  subsequently. 
With  this  ulcus  durum  he  commenced  treatment  with  me.  I immediately 
began  the  injections,  continuing  them  with  but  few  interruptions,  and 
in  doses  of  gr.  of  sublimate,  without  any  noticeable  effect  on  the 
induration. 

After  using  it  for  six  weeks,  in  all  about  2 gr.  of  sublimate  having 
been  administered,  the  patient  went  home,  during  a vacation.  Here  he 
was  treated,  according  to  the  view  of  a resident  physician,  for  eight 
weeks,  with  inunction  of  mercury,  £ dr.  daily.  This  treatment  had, 
according  to  the  patient’s  views,  a contrary  effect,  not  producing  the 
expected  diminution  of  the  sclerosis.  There  was  rather  an  increase  of 
the  disease,  extending  over  the  whole  prepuce,  causing  pliymosis. 

Simultaneously,  the  enlarged  tonsils  showed  highly-raised  mucous 
papules,  which  would  neither  give  way  by  gargarisms  of  kali  chloricum 
nor  by  cauterization  with  argentum  nitras  ; so  that  the  attending  phy- 
sician declared  them  to  be  a mercurial  affection. 

The  patient  returned  in  November  to  Berlin,  and  saw  me  again.  On 
examination,  I found  on  both  tonsils  grayish-white  excrescences,  of  the 
size  of  a pea,  showing  clearly  a syphilitic  character.  Inasmuch  as  the 


82 


INDICATIONS  FOR  INJECTION. 


internal  medication  from  iodide  of  potassium  proved  without  result  for 
a fortnight,  I resorted  again  to  the  injections  of  the  strength  of  gr. 
per  diem — resulting,  in  three  weeks,  in  a perfect  cure,  with  the  entire 
disappearance  of  plaques  muqueuses. 

Ulcerative  processes  of  the  different  regions  of  the  pha- 
rynx are,  in  the  later  period  of  syphilis , of  a more  destruc- 
tive and  deeper  going-in  character,  as  illustrated  in  the  de- 
tails of  the  above  cases. 

As  to  the  genesis  of  those  ulcerations,  there  is  hut  one 
voice,  that  the  origin  is  to  be  found  exclusively  in  the  so- 
called  gummy  tumors , of  which  there  are  two  varieties , 
namely,  the  diffuse  gummy  infiltration  and  the  isolated  cir- 
cumscribed knots — gummy  knots — nar'  et-oxyv. 

The  authors  give  not  only  a very  detailed  description  of 
this  formation,  but  even  describe  their  course  and  formative 
process  very  minutely.  Especially  is  their  seat  on  the  pos- 
terior surface  of  the  velum  palati  and  on  both  angles  formed 
by  the  velum  and  uvula,  described.  Like  the  gummata  of 
the  outside  skin,  they  develop  themselves  in  a slow  and 
painless  manner  on  the  mucous  membrane  or  sub-mucous 
tissue,  either  in  single  or  group-like  knots,  of  the  size  of  a 
pea  or  bean.  Although  plainly  divided  from  their  sur- 
roundings, they  appear  less  prominent  and  less  hard  and 
circumscribed. 

By  and  by  the  infiltration  pushes  against  the  most  super- 
ficial layers  of  mucous  membrane,  which  softens.  The 
membrane  quickly  reddens,  the  inflammation  increases,  and 
sometimes,  after  a few  hours,  from  an  “ imperfect  examina- 
tion,” the  knots  “ perforate,  and  on  the  velum  we  find  an 
irregular,  round,  funnel-shaped  ulcer,”  &c. 

Seeking  after  this  detailed  process  of  formation,  the  real 
material  upon  which  these  observations  were  based,  it 


AFFECTION  OF  THE  MOUTH  AND  PHARYNX. 


83 


seems  strange  that,  with  the  exception  of  but  two  contra- 
dictory observations  from  the  French  literature,  no  other 
author  till  the  present  time  has  confirmed  a case  of  the  so- 
called  gummy  tumor  in  its  integrity,  before  its  destruction, 
or  noted  the  perforation  of  the  velum.  The  authors  above 
alluded  to  are  Bouisson  and  Parmentier.  One  refers  to  the 
subject  thus:  “ Chez  plusieurs  malades  atteints  de  syphilis 
inveter^e  des  indurations  tantot  circonscrites,  tantot  diffuses, 
du  voile  du  palais  sans  ulcerations  de  sa  membrane  de 
revetement.”  The  other  describes  “ces  tumeurs  gom- 
meuses”  as  “petites  et  a peine  sensibles  au  debut,”  “ ad- 
herentes  a la  muqueuse  par  une  sorte  pedicule  et  mobiles 
sous  les  parties  sous-jacentes  et  voisines.”  The  form  of 
pedicled  gummy  tumors  described  by  Parmentier  is  not  only 
in  contradiction  with  all  present  descriptions,  but  is  the 
reverse  of  the  known  histological  nature  of  them  altogether. 
Laying  in  the  parenchyma  of  the  tissue,  never  has  there 
been  found  a trace  of  pedicled  insertion. 

But  if  we  go  over  to  the  other  authors,  who  seem  to  de- 
scribe so  accurately  the  course  and  progress  of  gummata  of 
the  velum  without  giving  a case,  wu  almost  find  an  excuse 
for  deficiency  of  cases  and  description  of  details  in  the  fact 
that  these  tumors  progress  without  being  noticed,  because 
they  are  situated  on  the  posterior  surface  of  the  velum,  and 
also  because  their  course  is  painless,  and  therefore  the  pa- 
tient but  very  seldom  by  his  complaints  arouses  the  suspi- 
cions of  the  physician.  One  author  goes  so  far  as  to 
explain  the  tumor  as  “invisible ,”  and  after  describing  it,  he 
recommends,  for  an  early  -diagnosis  of  this  latent  disease, 
that  the  physician  feel  of  the  posterior  part  of  the  velum,  or 
examine  the  locality  with  the  rhinoscope. 

But,  granted  that  this  manual  examination  (described  by 


84 


INDICATIONS  FOR  INJECTION. 


another  author  as  “ troublesome”)  is  of  some  account,  I 
wish  to  emphasize  here  that  the  prognosis  seems  nowhere  to 
be  published,  at  least  I have  not  found  it. 

Concerning  the  rhinoscopic  examination,  I would  say, 
this  method,  even  in  a normal  state  of  the  velum,  is  very 
difficult,  and  more  so  must  it  be  when  the  tissue  by  layers  of 
small  knots  has  increased  in  volume,  and  thus  filling  up  the 
already  narrow  cavum  pharvngo-nasale. 

By  my  quotations,  one  can  see  that  here,  as  in  many  other 
important  questions  in  medicine,  a traditional  view  has  crept 
along  without  any  sure  foundation,  and  has  been  handed 
from  author  to  author.  Such  views,  sanctioned  by  tradi- 
tion and  impressing  us  with  the  idea  that  darkness  must 
have  hovered  over  the  processes  investigated,  yet  already 
better  understood,  are  the  cause  why  later  authors  do  not 
take  the  care  to  re-investigate  for  themselves  anew. 

It  seems  to  me  as  if  all  authors  drew  their  conclusions 
“per  analogium .”  Proceeding,  for  example,  with  a right 
view  as  to  the  formation  of  gummy  processes  on  the  outside 
skin,  they  conclude  that  the  gummata  are  brought  about  in 
the  same  manner  on  the  velum  and  posterior  wall  of  the 
pharynx.  But  whether  this  is  really  so  or  not,  or  whether 
there  are  other  pathological  circumstances  connected  with 
it,  requires  further  investigation  to  determine. 

My  own  observations  have  not  enabled  me  to  study  the 
progress  of  a gummy  formation,  neither  on  the  velum,  nor 
tonsils,  nor  the  posterior  part  of  the  pharynx.* 

* Maisonneuve  (’Lemons  Cliniques  sur  les  Maladies  cau  cereuses, 
Paris,  1854)  narrates  a case  in  which  he  had  healed  a tumor  of  the 
pharynx  by  iodide  of  potassium,  which,  after  removal  by  an  operation 
of  Blundins,  appeared  again. 


AFFECTION  OF  THE  MOUTH  AND  PHARYNX. 


85 


Knots  of  the  described  variety,  but  which  resembled 
more  the  lupus  kind,  I have  seen  several  times  in  the  paren- 
chyma of  the  tongue,  but  they  did  not  terminate  in  ulcera- 
tion. On  the  other  hand,  I have,  in  all  those  cases  where  I 
found  ulcerations,  as  on  the  soft  palate  and  posterior  part  of 
the  pharynx,  never  seen  knots  preceding  them  in  a primary 
form,  nor  as  a casual  coincidence  of  their  formation. 

Only  on  the  palatum  durum  have  I detected,  as  a follow- 
ing case  will  show,  a tumor  which,  on  account  of  its  shape 
and  consistence,  could  be  named  “gummous.” 

The  processes  which  I had  occasion  to  observe  on  the 
velum  were  either  recent,  or  processes  which  had  already 
existed  for  a long  time. 

In  the  first  category  belong : 

1.  j Diffuse  infiltration , of  greater  extension,  of  hard  con- 
sistence and  of  a bluish-red  color,  plainly  divided  from  the 
palatum  durum.  The  connection  of  ulcerative  destruction 
of  such  an  infiltrated  velum,  I had  not  occasion  to  observe, 
because,  by  energetic  medication,  resolution  of  the  infiltra- 
tion readily  occurred. 

2.  Diffuse  infiltration,  just  passing  into  ulceration , which 
involved  more  or  less  of  the  velum,  uvula  and  arches — 
having  produced  in  its  course  loss  of  substance  more  or  less 
deeply. 

Secretion  of  such  ulcers  is  not  very  profuse.  The  color 
is  generally  yellow-white,  and  often  firmly  embedded  in  the 
tissue,  as  in  diphtheritis. 

In  some  cases  the  erosion  wTas  in  its  incipiency,  in  others 
the  tonsils  were  already  wholly  destroyed,  and  I could  only 
see,  instead,  the  ulcerated  surface  of  the  infiltrated  Avails  of 
the  anterior  and  posterior  roofs  of  the  palate  toAvards  the 
fovece  tonsillares . 

8 


86 


INDICATIONS  FOR  INJECTION. 


3.  Single  circumscribed  ulcerations  reaching  deeper  into 
the  tissue  of  the  velum  and  already  threatening  perforation . 
They  consisted  mostly  of  an  encircled,  infiltrated,  livid-red 
tissue,  covered  with  a puriform  secretion  and  putrid  detritus. 

The  condition  of  these  ulcers  was  in  no  case  so  fixed  that 
I could  draw  a conclusion  as  to  its  origin,  especially  whether 
resulting  from  pustules  or  gummy  knots. 

4.  Ulcerations  which  already  had  given  rise  to  infiltra- 
tion, and  extensive  defects , mostly  of  the  velum  and  uvula . 

As  to  the  second * category  of  the  long-existing  processes , 
I saw : 

1.  Perforation  of  the  velum , of  small  extension , when  the 
surroundings  only  showed  a relatively  insignificant  inflam- 
mation. 

2.  Entire  or  partial  deficiency  of  the  uvula  and  velum  and 
posterior  palate  roof  \ — having  resulted  in  a gluing  together 
of  the  remaining  portions  to  the  posterior  wall  of  the 
pharynx . In  such  cases  once  in  awhile,  particularly  at  the 
upper  point  of  the  glued,  adherent  end,  small  ulcers,  of  a 
non-syphilitic  nature,  were  visible.  They  chiefly  originated 
from  the  mechanical  effect  of  stretching  and  friction  during 
deglutition  and  phonation,  to  which,  being  grown  together 
and  non-elastic,  the  parts  were  subjected. 

The  subjective  complaints  of  the  patient  in  all  these  men- 
tioned cases  arose  naturally  enough,  considering  the  physio- 
logical functions  of  the  affected  parts,  and  also  the  lymphatic 
vessels,  with  commencing  inflammatory  processes.  The 
patients  complained  of  a very  troublesome  gathering  of 
phlegm  mixed  with  pus,  and  sometimes  even  with  blood, 
thus  causing  a continual  expectoration.  Another  part  of 
the  complaints  is  produced  by  the  gluing  together  of  the 
velum  and  the  posterior  wall  of  the  pharynx,  which  greatly 


AFFECTION  OF  THE  MOUTH  AND  PHARYNX.  87 

interferes  with  deglutition  and  phonation.  In  consequence 
of  the  destroyed  part  of  the  cavum  pharyngo-nasale,  a nasal 
sound  of  the  voice  is  produced  and  a regurgitation  of  the  food 
through  the  nose  takes  place. 

Concerning  the  other  affections  of  the  pharynx  which 
have  to  he  noticed  here,  I have  already  mentioned  that  only 
in  one  case  had  I occasion  to  see  a tumor  on  the  hard  palate 
that  might  have  been  “gummous”  (Case  12). 

On  the  tonsils , that  very  singular  glandular  apparatus  of 
the  pharynx,  I have  very  often  seen,  and  mostly  in  a rela- 
tively early  stage  of  syphilis,  the  well-known  extensive 
swellings  which  occlude  the  isthmus  faucium  to  a great 
extent.  Syphilitic  knots  are  generally  said  to  occasion 
this,  but  I never  succeeded  in  seeing  or  feeling  them.  And 
so  far  as  I know,  there  has  not  been  a single  author  of 
pathological  anatomy  who  has  observed  or  described  a case. 

On  the  posterior  wall  of  the  pharynx  I had  several  times 
occasion  to  see  and  treat  successfully  syphilitic  ulceration. 
The  formation  of  the  ulcer  is  generally  round  with  seldom  a 
ragged  or  irregular  edge ; the  color  mostly  grayish ; the 
secretion  doughy,  bad  smelling  and  of  a pus-like  consistence. 

That  these  ulcers  here  have  their  origin,  not  on  account 
of  mercurialization,  (a  thing  much  emphasized  by  anti-mer- 
curialists,)  is  evident,  “ ex- juv antibus  et  nocentibusf  because 
all  the  ulcers  healed  with  the  treatment  of  subcutaneous 
injections  of  mercury  quickly  and  thoroughly. 

Concerning  the  therapeutics  of  the  pharynx  the  same 
indications  prevail  here  as  with  affections  of  the  larynx,  and 
I shall  speak  more  fully  on  this  point  in  the  next  chapter. 

In  the  selection  of  the  following  cases  I have  taken  those 
in  which  either  interesting  pathological  processes  occurred, 
or  in  which  the  effect  of  the  subcutaneous  medication  was 


88 


INDICATIONS  FOR  INJECTION. 


clearly  visible.  The  following  case  shows  that  even  a per- 
forated ulcer  on  the  soft  palate  may  be  fully  healed  and  the 
perforation  closed,  if  only  early,  energetic,  hypodermic 
injections  of  sublimate  are  employed. 

Case  9. — A merchant,  W.  M.,  twenty-eight  years  old,  coming  from 
a healthy  family,  suffered  in  his  childhood  with  “ tetanic  convulsions 
and  loss  of  consciousness.”  Later  he  had  acute  muscular  rheumatism. 
His  first  venereal  infection  dates  from  the  year  1860  and  consisted  of 
an  ulcus  durum , for  which  he  used  for  four  weeks  continuously  iodide 
of  mercury.  Six  months  subsequently  there  was  a reappearance 
of  the  syphilis  in  the  form  of  psoriasis  palmaris , for  which  the  same 
treatment  was  used  with  success. 

Three  years  after  he  had  inflammation  of  the  e}re  which  was  diagnos- 
ticated as  syphilitic  iritis — with  a later  return  of  the  psoriasis  palmaris. 

In  the  beginning  of  the  year  1868  Dr.  Wallmueller,  his  family  phy- 
sician, being  consulted  on  account  of  his  throat,  detected  a suspicious 
ulcer  on  the  soft  palate,  and  immediately  sent  the  patient  to  me. 

I perceived  the  presence  of  a perforating  ulcer  on  the  soft  palate  somewhat 
larger  than  a bean  on  the  right  side  of  the  uvula.  The  borders  were  well 
defined , and  the  secretion  purulent , of  a fatty  appearance  but  not  very 
abundant. 

Besides  swelling  of  the  inguinal  and  cervical  glands,  there  was  no 
other  sign  of  syphilis.  I commenced  with  the  sublimate  injections,  the 
patient  visiting  me  daily.  But  after  the  tenth  liypordermic  dose,  acute 
muscular  rheumatism  set  in,  and  the  patient  was  obliged  to  remain  in  bed 
a fortnight.  After  pausing  a few  days,  I recommenced  the  treatment  at 
the  patient’s  house,  notwithstanding  the  very  marked  febrile  symptoms. 
After  using  the  amount  of  3J  gr.  of  the  sublimate  the  ulcer  was  com- 
pletely cured  and  the  perforation  closed.  It  is  noticeable  that  the  course 
of  the  acute  muscular  rheumatism , according  to  the  patient  and  family  physician 
was,  with  the  sublimate  injections , a shorter  and  milder  one  than  usually. 

The  next  following  case  is  interesting  from  the  fact,  aside 
from  the  quick  result  of  the  subcutaneous  injection,  in  oppo- 
sition to  the  already  used  treatment  with  iodide  of  potassium 
without  restoration,  that  it  is  a sure  proof  that  ulcerous 


AFFECTION  OF  THE  MOUTH  AND  PHARYNX. 


89 


syphilitic  affections  (and  in  this  case  an  ulcer  of  the  soft 
palate),  do  arise  without  having  previously  used  mercury. 

Case  10. — Joseph  S.,  twenty-two  years  old,  of  sound  parents  and  of  a 
healthy  habitus,  has  always  been  in  good  health  with  the  exception  of 
pneumonia,  from  which  he  recovered  ht  the  age  of  ten,  and  a slight 
rheumatic  affection  of  the  left  knee  joint. 

In  the  month  of  July,  1868,  he  became  infected,  and  according  to  his 
statement,  a small  pustule  was  formed  on  the  inner  lamella  of  the  pre- 
puce, and  out  of  which  he,  himself,  pressed  the  pus-like  secretion.  It 
seemingly  healed  with  only  a dry  bandage.  Six  months  afterwards  he 
had  pains  in  his  throat  and  he  called  on  a physician,  who  prescribed 
3g  of  iodide  of  potassium,  after  which  the  affection  left.  After  a time 
_the  pains  in  the  throat  returned,  and  notwithstanding  this,  and  a dis- 
covery by  inspection  of  his  own  pharynx,  of  the  presence  there  of 
“whitish  ulcers,”  he  neglected  to  seek  relief  from  a physician. 

February  6th,  1869,  patient  consulted  me.  I found  on  the  prepuce, 
at  the  place  of  the  former  ulcer,  a cicatrized,  white  appearance  of  skin 
devoid  of  pigment,  having  a rather  indurated  feeling.  The  neighboring 
inguinal  and  more  distant  lymphatic  glands  were  in  a normal  state. 
On  the  left  nostril  was  an  ecthymous  incrustation.  Small  knots  of  the 
size  of  the  smallest  shot,  and  covered  with  the  thinnest  hard  dry  coat- 
ing, were  near  the  region  of  the  left  corner  of  the  mouth,  and  on  the 
forehead  close  to  the  border  of  the  hair.  The  inner  walls  of  the  nostrils 
were  slightly  eroded,  somewhat  swollen,  and  covered  with  a rather 
thick  greyish  hard  coating. 

The  whole  of  the  soft  palate  with  the  uvula  and  palate  roofs  were  consider- 
ably infiltrated  and  covered  in  its  whole  extension  with  a number  of  greater  or 
smaller  ulcerations.  The  ulcers  themselves  reach  in  some  parts , deeply  into 
the  tissue , being  sharp  pointed  and  reaching  island-like  over  each  other.  The 
tonsils  I found  completely  destroy ed,  also  the  inner  walls  of  both  palate  roofs 
showing  deep-seated  destruction . Secretion  of  the  ulcers  is  of  white , caseous, 
mushy-like  appearance , and  so  adherent  that  in  trying  to  remove  it,  bleeding 
commenced. 

On  account  of  great  swelling  of  the  soft  palate,  a desirable  rhino- 
scopic  examination  could  not  be  made.  The  laryngoscopic  examination 
did  not  reveal  anything  abnormal. 

Deglutition  is  somewhat  painful  and  the  voice  somewhat  dulled. 

8* 


90 


INDICATIONS  FOR  INJECTION. 


I began  immediately  the  hypodermic  injections  in  \ gr.  doses  per  diem , 
and  after  using  3 gr.  altogether,  a complete  cure  was  accomplished. 

In  the  following  patient  we  see,  after  a treatment  by  the 
subcutaneous  method,  but  probably  on  account  of  too  small 
a quantity,  ulcerations  springing  up  on  the  soft  palate. 
With  a continuance  of  the  injections  she  was  cured. 

Case  11. — Henrietta  K.,  twenty  years  old,  has  been  treated  five  dif- 
ferent times  in  our  hospital  for  syphilis — once  locally,  three  times  with 
the  sarsaparilla  sweat  cure,  and  the  fifth  time  by  subcutaneous  medica- 
tion with  the  sublimate,  using  altogether  1J  grains.  The  affections 
consisted  mostly  of  broad  condylomes,  maculous  and  papulous  exan- 
themata, besides  condylomatous  ulcerations  of  the  soft  palate. 

She  came  under  my  care  the  sixth  time  February  12th,  1869,  and  we 
found  besides  condyl.  acum.  near  the  labia  majora  an  ulceration,  quite 
extensive,  on  the  palatum  durum.  On  the  right  half  of  the  soft  palate , on 
the  anterior  and  even  on  the  posterior  part , examined  with  the  rhinoscope)  we 
saw  ulcerations  which  had  destroyed  nearly  one  half  of  the  uvula.  The 
remaining  part  was  hanging  doivn  loosely.  The  base  of  the  ulcer  had  a yellow 
appearance , with  edges  sharply  defined , not  much  reddened , with  secretion  very 
scant.  Deglutition  was,  strangely,  not  much  interfered  with.  The 
lymphatic  glands  in  the  submaxillary  and  cervical  regions  were  much 
swollen,  and  those  in  the  inguinal  region  but  slightly.  On  account  of 
the  robust  appearance  of  the  patient,  we  used,  at  once,  \ gr.  sublimate 
hypodermically  : but  this  dose  seemed  too  strong,  as  appearances  of 
mercurial  intoxication,  with  diarrhoea  and  colic,  also  vertigo,  were  soon 
manifested.  After  a pause  of  two  days  we  resumed  treatment,  giving 
J gr.  and  soon  J gr.  doses  of  sublimate,  without  any  hurtful  effects,  so 
that  in  seventeen  days  the  patient  was  discharged  completely  restored 
to  health. 

With  the  following  patients  there  is,  beside  ulcerations  on 
the  palatum  durum , a tumor  justifiably  called  “gummy.” 

Case  12. — Albert  S.,  twenty-seven  years  old,  mason  by  trade,  of 
healthy  parentage,  was  up  to  his  twenty-fourth  year  of  excellent  health, 
when  he  contracted  a hard  chancre  which  developed  its  presence  four 
weeks  after  coitus.  He  remained  without  any  treatment,  a stain-like 


6(yvL^C  otcJ 


/ f^Z. 


AFFECTION  OF  THE  MOUTH  AND  PHARYNX. 


91 


exanthem  appearing.  He  began  now  to  use  a mercurial  treatment, 
which  induced  a latency  in  the  disease  for  eighteen  months,  when  a 
relapse  occurred  in  the  form  of  syphilitic  throat  affection,  which  is 
reported  to  have  been  an  erosion  of  the  pharynx.  But  in  spite  of 
various  treatments  with  iodide  of  potassium  and  mercury,  extensive 
destruction  of  the  soft  palate  was  produced,  followed  by  necrosis  of 
the  palatum  durum  and  exfoliation  of  several  pieces  of  bone.  He  was 
recommended  to  use  Dzondi’s  pills,  but  without  any  result.  Soon  the 
nasal  bones  became  involved.  On  the  18th  of  June,  1868,  he  was 
admitted  to  the  Charite  with  the  following  status  pr as ens : Patient  of 
gracile  habitus,  pale  and  anaemic  in  color,  very  much  emaciated,  weak 
muscles  and  shrivelled  skin,  with  inflammatory  swelling  of  the  gums, 
probably  consequent  upon  recent  salivation. 

j Exploration  of  the  'pharynx  showed  putrid  ulcers  on  the  hard  palate , of 
offensive  odor,  and  with  an  already  extensively  existing  ulceration  of  the  bone. 
It  was  possible  to  reach  through  the  hard  palate  into  the  cavum  narium  with  a 
common  catheter.  In  the  middle  of  the  right  half  of  the  hard  palate,  a tumor 
was  to  be  seen  of  the  size  of  a bean , elastic  to  the  touch,  borders  well  defined 
and  of  a reddish  yellow  color.  It  very  easily  could  be  taken  for  a gummy 
knot.  On  the  septum  narium  there  were  also  large  unclean  ulcers  having  a 
fetid  smell.  The  other  regions  of  the  pharynx  and  larynx  were  intact.  On 
the  prepuce  there  was  a hard  cicatrix,  and  on  the  left  testicle  a gummy 
swelling  of  the  size  of  a hazel-nut,  and  painful  when  touched. 

On  account  of  a mercurial  stomatitis  we  used  a gargarism  of  chlorate 
of  potash  and  the  same  internally.  This  trouble  having  subsided  in 
the  course  of  five  days,  we  began  to  use  injections  of  sublimate,  com- 
mencing with  J gr.  per  diem,  but  soon  reaching  J gr.  daily. 

The  patient  endured  the  course  of  medication  very  well,  but  on 
account  of  constipation  laxatives  had  to  be  used  occasionally. 

Whenever  prodromes  of  stomatitis  mercurialis  occurred,  an  interruption 
of  treatment  for  eight  days  was  ordered. 

After  having  used  the  amount  of  6 grains  of  sublimate,  the  patient 
was  discharged  cured,  in  the  middle  of  August,  1868.  The  local  treat- 
ment of  the  “gummy  tumor”  on  the  scrotum  consisted  in  binding  it 
with  straps  of  sticking  plaster.  The  ulcers  of  the  nose  and  cavity  of 
the  mouth  were  pencilled  with  argentum  nitricum,  they  cicatrizing 
over  completely.  The  perforation  itself  was  closed,  so  that  a small 
opening  only  remained. 

April  7th,  1869,  he  introduced  himself  again  to  me,  and  I was  con- 
vinced of  the  completeness  of  the  cure. 


92 


INDICATIONS  FOR  INJECTION. 


The  following  patient  from  my  private  practice  showed 
destruction  of  the  pharynx  and  nose — the  first  I have  met 
where  it  existed  to  such  an  extent.  Medical  literature 
seems  to  have  described  such  cases  but  very  seldom. 

Case  13. — Henrietta  R.,  thirty  years  old,  of  cachectic  appearance, 
delicate  constitution,  pale,  anaemic  color  of  the  countenance,  flabby 
muscles  and  parched-like  skin,  was  healthy  in  her  youth.  She  was 
infected  with  syphilis  for  the  first  time  when  twenty-five  years  of  age. 
The  patient  is  apathetic  and  rather  stupid,  and  therefore  nothing  reli- 
able could  be  ascertained  from  her.  The  first  symptoms  reported  were 
ulcerative  affections  of  the  genitals,  for  which  only  external  remedies 
had  been  used,  like  lotions,  washes,  &c.  She  repeatedly  assured  us 
that  she  had  never  taken  any  internal  remedies . 

A year  later  she  was  admitted  into  the  Charite.  The  history  of  her 
case  was  lost  or  could  not  be  found.  According  to  the  patient,  she  had 
sores  on  the  body  and  in  the  mouth,  and  the  sarsaparilla  sweat  cure 
and  iodide  of  potassium  constituted  her  medication. 

December  22d,  1868,  she  was  again  admitted  into  my  wards,  and  the 
status  praesens  was  that  on  the  whole  body  there  were  white,  shining, 
star-like  cicatrices  of  different  sizes,  as  is  often  seen  in  consequence  of 
lupous  ulcerations.  The  face  and  forehead  had  large  scarred. surfaces. 
In  the  middle  of  the  forearm  a lupous  superficial  ulcer  could  be  seen, 
of  the  size  of  a Prussian  dollar,  with  sharp  undermined  borders  and  a 
thick,  pus-like  secretion.  The  cavity  of  the  mouth  and  nose  showed  marked 
destruction.  By  the  complete  absence  of  the  soft  palate  and  almost  total  dis- 
appearance of  the  hard  palate , both  cavities  were  united  into  one.  Of  the 
hard  palate  there  was  remaining  only  an  arch  of  two  shreds , the  larger  of 
which , the  size  of  a common  goose  quill , ran  from  the  right  side  of  the  upper 
jaw  towards  the  posterior  wall  of  the  pharynx  and  was  attached  thereto.  The 
smaller  shred , the  size  of  the  quill  portion  of  a hen's  feather , commenced  from 
the  right  pterygoid  process , reaching  oppositely  in  the  direction  of  the  maxilla 
superior . 

In  the  nasal  cavity , the  conchae  superiores , mediae , and  inferior cs  were  also 
destroyed.  The  openings  of  both  tubae  Eustachii  were  easily  visible.  The 
remaining  mucous  membrane  on  the  eroded  locality  was  covered  with  a pus- 
like secretion  of  an  offensive  odor.  On  the  posterior  wall  of  the  pharynx , 
there  were  deep-seated  syphilitic  ulcers  of  the  size  of  a penny.  She  was  per- 


AFFECTION  OF  THE  MOUTH  AND  PHARYNX. 


93 


fectly  aphonic.  Deglutition  was  surprisingly  easy , on  account  of  the  patient 
bending  back  the  head  somewhat , when  taking  solids  or  fluids. 

Laryngoscopic  examination  revealed  only  a thickening  of  the  epiglottis. 
All  the  remaining  organs  were  intact. 

It  was  noticeable  that  the  patient  had  been  pregnant  six  or  seven  months. 

Our  treatment  was  subcutaneous  injections  of  the  sublimate,  and 
common  injections  of  chlorate  and  permanganate  of  potassium  into  the 
cavity  of  the  mouth  and  nose. 

We  had  frequent  interruptions  of  the  sublimate  treatment  on  account 
of  salivation  occurring.  For  this  reason  we  used  iodide  of  potassium 
internally,  but  had  to  return  to  the  subcutaneous  use  of  the  sublimate 
again  in  order  to  bring  about  a cure. 

After  using,  in  the  course  of  three  months,  2|  gr.  of  sublimate,  the 
lupous  ulcer  on  the  arm  was  cicatrized  and  also  the  ulceration  of  the 
pharynx.  The  mucous  membrane  of  the  cavity  of  the  nose  and  mouth, 
which  as  noticed  were  in  open  communication,  was  rid  of  all  secretion. 

The  looks  of  the  patient  were  so  altered,  and  according  to  her  own 
statement  she  felt  quite  well,  that  we  discharged  her  cured. 

Case  14. — F.,  twenty-eight  years  old,  a blacksmith  by  trade,  of  a 
delicate  constitution,  flabby  muscles,  sallow  complexion,  and  already 
gray  hair,  was  taken  into  the  Charite  December  29th,  1866. 

Patient  had  a chancre  in  1857,  for  which  he  used  blue  pills.  Another 
similar  affection  was  only  locally  treated.  In  1863  he  had  chancre  for 
the  third  time,  and  used  only  calomel  till  it  produced  salivation.  His 
present  condition  he  noticed  only  since  three  weeks  previously. 

Examination  revealed  an  ulcer  of  the  size  of  a penny  and  deeply  seated , 
covering  the  anterior  and  posterior  left  roof  of  the  palate  and  even  the  tonsils. 
It  had  destroyed  a portion  of  this  region  in  such  a manner  that  a cavity  the 
size  of  a gold  dollar  was  produced.  The  chest  was  covered  with  papulous 
and  vesiculous  exanthemata.  The  lymphatics  in  the  different  region  * 
were  only  slightly  swollen. 

I commenced  using  injections  hypodermically  of  J gr.,  but  soon 
increased  strength  to  ^ gr.  Already  after  the  use  of  1 gr.,  the  described 
ulcer  was  clean  and  partially  covered  with  epidermis.  The  exanthemata 
were  mostly  healed  also.  After  using  2|  grains  of  sublimate  and  2 
drachms  of  iodide  of  potassium,  the  patient  was  discharged  cured. 


Case  15. — Anna  K , twenty-six  years  old,  been  already  three  times  in 


94 


INDICATIONS  FOR  INJECTION. 


the  Charite  during  the  last  five  years,  but  was  only  locally  treated,  and 
was  admitted  again  October  1st,  1868. 

Present  condition. — Patient  is  of  good  healthy  appearance ; has  on 
the  genitals  only  slight  erosions,  small  ulcers  on  both  labia  majora  and 
ft  cicatrix  on  the  posterior  commissure  of  the  vagina.  There  are  only  a 
few  dirty,  pigment-colored  patches  on  the  body.  Examination  of  the 
pharynx  showed  an  infiltration  of  the  greatest  part  of  the  soft  palate , which 
was  sharply  divided  from  the  normal  color  and  quality  of  the  hard  palate. 
Left  of  the  uvula  there  was  an  ulcer  of  the  size  of  a penny , perforating  the 
velum , with  ragged , undermined , infiltrated  borders. 

The  lymphatic  glands  were  swollen  in  the  inguinal  and  submaxillary 
regions,  and  more  still  in  the  cervical.  In  doses  of  -J-  gr.  each  of  subli- 
mate, thirty-one  injections  were  given  which,  together  with  local  treat- 
ment, cured  the  patient,  so  that  she  was  discharged  in  thirty-two  days. 

In  the  following  cases  no  sure  criterion  of  a syphilitic 
affection  could  be  found. 

Case  16. — Bernhardine  K.,  twenty-one  years  old,  was  taken,  October 
20th,  1868,  into  our  hospital,  with  the  following  symptoms:  Pigment 
patches  over  the  whole  body,  more  or  less  spread,  genitals  of  normal 
size,  lymphatic  glands  nowhere  swollen;  deep  ulcerations  on  the  posterior 
roofs  of  the  palate , and  both  tonsils  destroyed.  A large  ulcer  on  the  soft 
palate  which  has  destroyed  the  greater  part  of  the  left  side,  extending  to  the 
border  of  the  hard  palate.  The  border  red  and  fatty -like,  is  partially  covered 
with  highly  elevated  granulations.  The  epiglottis  thrice  as  large  as  natural , 
especially  on  the  right  side , with  superficial  erosion.  An  ulceration  existed , 
of  the  size  of  a pea  on  the  left  processus  vocalis.  The  left  vocal  cord  was 
somewhat  infiltrated. 

After  twenty-five  injections  amounting  to  4 gr.  in  all,  the  patient  left 
cured,  having  stayed  five  weeks  only. 

Case  IT. — Mrs.  S.,  forty-eight  years  old,  received  into  the  hospital 
October  16th,  1868.  Nothing  could  be  found  on  the  body  indicating 
syphilitic  affection. 

In  the  pharynx , the  greatest  part  of  the  soft  palate  was  destroyed , and  the 
remainder  glued  on  the  posterior  wall  of  the  cavity  of  the  mouth.  * On  the 
border  of  this , was  an  ulcer  of  the  size  of  a penny , covered  with  a putrid 
dirty,  pus-like  secretion , the  edges  being  undermined.  On  the  mucous  mem- 
brane of  the  nasal  cavity , superficial  ulcers  were  found , partly  incrusted. 

Complete  restoration  in  four  weeks  was  brought  about  by  the  use  of 
twenty-five  injections  of  £ gr.  each. 


AFFECTION  OF  THE  MOUTH  AND  PHARYNX.  95 

Case  18. — G.,  a drover,  thirty-five  years  old,  taken  into  the  hospital 
August  12th,  1867. 

Examination  revealed  extensive , deep-seated  ulcerations , with  hollow , 
reddened  borders , and  covered  with  a yellow , pus-like  secretion , situated  on 
the  soft  palate.  There  was  a destruction  of  one  half  of  the  entire  uvula 
reaching  more  upon  the  left  side  to  the  middle  of  the  velum. 

Ulcerations  of  a slighter  character  and  smaller  extension  were  seated 
on  the  posterior  part  of  the  pharynx  and  left  palate  roof.  Patient  had 
two  years  previously  an  ulcer  and  different  exanthematous  eruptions. 

He  used  mercury  internally.  The  present  condition  only  developed 
itself  a few  weeks  ago.  No  other  syphilitic  complication  could  be  found 
on  the  body.  Subcutaneous  injections  of  J gr.  each,  completed  the 
cure  in  twenty-one  days. 

Infectio  per  os. — As  known,  there  is  quite  a controversy 
concerning  the  important  question  whether  syphilitic  infec- 
tions can  only  be  produced  with  direct  contact  of  the  genitals, 
or  if  also  other  places  of  the  body  may  be  original  openings 
for  infection. 

Although,  the  oldest  authors  on  syphilis  were  obliged  to 
consent  to  a possibility  of  a direct  infection  by  way  of  the 
lips , and  even  Torella,*  Fernelius,f  &c.,  reported  several 
cases,  yet  since  the  dualistic  view  of  the  nature  of  the  syphi- 
litic virus  has  gained  more  ground,  the  development  and 
origin  of  primary  syphilitic  sclerosis  vid  the  lips  has  been 
entirely  denied  by  Ricord  and  his  disciples. 

Only  after  Ricord’s  theories  on  the  changing  of  the  soft 
chancre  into  the  hard  were  completely  refuted  by  exact 
experimental  demonstration,  and  especially,  after  the  fact 
was  established  that  syphilis  could  be  inoculated  from  every 


* Et  hoc  accidit  propter  mammas  infectas,  aut  faciem , aut  os  nutricis 
seu  cujus  alterius. 

f Juvenem,  mulierem  gallico  morbo  depravatam,  ore  exosculare 
assuetum  nullo  per  jovem  exercitatio  coitu,  in  morbum  gallicum  inci- 
disse. 


96 


INDICATIONS  FOR  INJECTION. 


syphilitic  secretion, — secretion  of  the  hard  chancre,  of  the 
broad  condylomes,  as  well  as  of  the  tonsils, — were  the  views 
of  Ricord  abandoned.  At  the  present  day  but  few  syphilo- 
graphs  dare  to  doubt  the  possibility  of  an  infection  per  os. 

There  have  recently  been  reported  so  many  cases,  espe- 
cially by  Fournier,  Rollet,  Koebner,  &c.,  with  proof  so 
corroborative,  that  the  above  remarks  are  well  substantiated. 

Further,  I had  a relatively  great  number  of  such  cases 
under  my  observation,  and  I may  be  permitted  to  narrate 
some  of  them  with  the  following  clinical  remarks  preceding. 

Generally  the  original  syphilitic  ulcer  on  the  lips  has  such 
a singular  character,  that  it  can  not  be  confounded  with  an 
abscess  produced  by  a condylomatous,  destructive  process. 
The  latter  may  have  entered  ever  so  largely  into  ulcerative 
metamorphosis , it  will  not  enter  the  tissues  so  deeply , nor 
have  such  a characteristic , hard , sharp-edged  basis  surround- 
ing it  as  the  ulcus  durum  of  the  lips.  Great  caution  must 
be  used  in  forming  a diagnosis  from  the  remaining  criterion. 
Here  also,  as  with  the  ulcus  durum,  the  principle  holds  good 
that  never  a single  symptom,  but  the  combination  of  all 
the  symptoms,  should  be  considered  and  have  the  prepon- 
derance. 

Of  great  value  for  the  decision  here  in  this  place  is  the 
seeming  absence  of  initial  syphilitic  affection  and  the  pre- 
sence of  an  intact  hymen  in  womeii.  And  as,  even  in  proved 
infection  via  the  lips,  a syphilitic  affection  may  occur  after- 
wards on  the  genitals  in  consequence  of  a syphilitic  diathesis, 
other  diagnostic  signs  must  be  considered.  These  are  the 
peculiar  course  and  development  of  the  lymphatic  glandular 
swellings,  which  show  themselves  much  sooner  in  the  region 
of  the  throat  than  in  the  inguinal  regions.  Generally  the 
submental  glands  swell  first,  especially  often  in  the  vicinity 


AFFECTION  OF  THE  MOUTH  AND  PHARYNX. 


97 


of  the  spina  mentalis  interna , between  the  insertion  of  the 
musculi  genio-hyoideus  and  genio-glossus.  Secondly,  those 
glands  inflame  which  are  situated  more  nearly  at  the  angle 
of  the  lower  jaw,  and  not  always  the  superficial  only,  par- 
tially covered  by  the  platysma  myoides , but  also,  even  some- 
times the  deeper  glands  which  are  scattered  in  the  trigonum 
cervicale,  and  which  receive  the  vasa  efferentia  of  the  gland- 
ule faciales  profunde.  In  one  case  where  the  ulcer  was 
situated  on  the  upper  lip,  I found  on  the  corresponding  left 
side  of  the  face  some  small  swollen  glands  in  front  of  the 
ear  near  the  parotis,  which  glands  may  be  termed  the  gland- 
ule zygomatice.  Only  after  these  glands  are  more  or  less 
inflamed  does  swelling  of  the  inguinal  glands  occur — pre- 
ceded in  some  cases  by  swelling  of  the  cubital  glands.  But 
here  it  must  not  be  forgotten  that  also  scrofulosis  brings 
about  similar  glandular  inflammation. 

Some  authors,  like  Zeissl  for  instance,  have  endeavored 
to  draw  a distinction  between  syphilitic  and  scrofulous 
swellings  of  the  lymphatic  glands,  as  largeness  and  uneven- 
ness of  the  scrofulous,  in  opposition  to  the  syphilitic. 

Koebner  characterizes  (page  62  of  his  Clinical  Reports) 
such  ulcerations  on  the  lips  and  mucous  membrane  of  the 
pharynx,  as  the  rapidly  developing  symptoms  of  the  usually 
later  period  of  syphilis,  which  may  be  named  “ syphilis 
gallopante  (galloping  syphilis),  causing  the  physician  to  fear 
for  the  life  of  his  patient. ” 

My  experience  does  not  at  all  verify  this  assertion,  as 
seen  in  the  following  cases.  It  may  be  different  when,  not 
the  lips,  but  the  finer  mucous  membrane  of  the  deeper  lying 
pharynx  is  infected  with  the  original  syphilis,  as  has  hap- 
pened in  some  cases  where  infection  resulted  from  catheter- 
izing  the  tuba  Eustachii.  In  the  greater  number  of  my 


98 


INEICATIONS  FOR  INJECTION. 


cases  the  symptoms  were  not  very  severe,  nor  were  they 
accompanied  by  fever,  nor  complications  fraught  with  danger. 
But  I must  remark  that  such  persons  were  generally  very 
anaemic  in  appearance,  and  the  cure  in  most  cases  was 
retarded. 

Case  19. — L.,  a merchant,  twenty-seven  years  old,  is  a son  of  sound 
parents.  He  says  he  has  only  once  ever  been  sick;  about  four  years 
ago,  with  inflammation  of  the  bowels.  A syphilitic  infection  he  denies 
most  emphatically , but  confesses  to  repeated  intercourse  with  women.  His 
present  disease  dates  back  to  December,  1868,  and  began  under  the  form 
*of  acute  angina  tonsillaris , and  he  says  the  swelling  of  the  right  submaxillary 
glands  was  rather  obstinate.  The  course  of  the  disease  was  a very  tedious 
one,  and  only  after  the  lapse  of  three  weeks,  and  several  incisions  of  the 
tonsils,  did  a change  for  the  better  take  place.  At  the  same  time  he 
had  a yet  existing  exanthema,  which  was  first  regarded  as  small-pox, 
and,  on  account  of  its  unyielding  nature,  the  patient  came  to  the 
hospital. 

Examination  on  the  13th  February,  1869,  revealed: 

A good  muscular  development  and  healthy  appearance.  The  genitals 
showed  no  ulcer  nor  cicatrix.  But  on  the  under  lip  there  was  a somewhat 
hard)  whitish-grey  colored  appearance  seemingly  a cicatrix.  The  whole 
body,  especially  the  chest  and  back , is  covered  with  dirty , reddish  papules 
of  the  size  of  common  shot.  Some  are  covered  on  the  point  with  a gray- 
white  epidermis,  others  have  become  metamorphosed  into  small  pus- 
tules. On  the  right  malleolus  externus  a small  swelling  was  detected , which 
seemed  to  arise  from  the  periosteum. 

Inspection  of  the  pharynx  and  cavity  of  the  mouth  revealed  an  erythema 
and  swelling  of  the  mucous  membrane,  the  tonsils  and  palate  roofs. 
On  the  right  side  of  the  posterior  wall  of  the  mouth  opposite  the  isthmus  fau- 
cium)  a scar  is  visible  about  five-sevenths  of  an  inch  long:  sharp-edged , some- 
what elevated  and  very  hard  to  the  touch. 

Laryngoscopic  examination  of  the  very  hoarse  patient  revealed  : 

Epiglottis  very  much  swollen . On  the  right  free  border , there  was  an  ulcer 
with  a firm  adherent  color , extending  towards  the  laryngeal  surface.  The 
cords  of  the  ligamentum  ary epiglottica , the  mesoarytenoid  folds  were 
swollen  and  the  vocal  cords  slightly  reddened.  The  glands  of  the 
tongue  were  swollen  and  partially  infiltrated,  and  here  and  there 
superficially  ulcerated. 


AFFECTION  OF  THE  MOUTII  AND  PHARYNX. 


99 


Rhinoscopic  inspection  showed  swelling  of  the  mucosa  of  the  cavum 
pharyngo-nasale,  covered  with  thick  tenacious  mucus. 

The  inguinal  glands  were  but  slightly  enlarged , but  the  cervical  and  sub- 
maxillary, particularly  the  latter,  were  swollen  on  the  right  side. 

Subcutaneous  injection  had  a quick  result  on  the  pharynx,  but  less 
so  on  the  papulous,  syphiloid,  which  only  after  the  use  of  J gr.  of  the 
sublimate,  began  to  disappear.  We  used,  altogether,  only  one  grain 
for  complete  restoration. 

Case  20. — Mr.  N.,  twenty-two  years  old,  originating  from  a family 
where  the  father  is  healthy,  but  where  the  mother  has  epilepsy,  had 
always  been  healthy  up  till  October,  1868,  when  he  discovered  on  the 
left  side  of  his  under  lip  a “ small  crack.”  This  u cracked  lip,”  as  he 
termed  it,  did  not  seem  to  heal  and  was  treated  by  his  family  physician 
with  glycerin  and  lastly  with  nitrate  of  silver,  but  without  result. 
After  an  elapse  of  three  weeks,  the  lymphatic  glands  on  the  side  of  the 
neck  began  to  swell.  Two  somewhat  carious  teeth,  thought  to  have 
caused  this,  were  extracted.  Notwithstanding,  the  “ cracked  lip”  grew 
worse  and  took  a form  like  glandular  swelling.  On  the  22d  November 
a celebrated  surgeon  was  consulted  and  diagnosed  chancre  of  the  lip. 
The  patient  consulted  me  a little  time  afterwards,  when,  except  from  a 
pale  appearance,  he  seemed  of  a healthy  constitution. 

The  submaxillary  glands , from  the  spina  mentalis  interna  to  the  angulus 
maxillse  inferioris  were  much  indurated  and  swollen.  On  the  under  Up  there 
was  an  ulcer  of  the  size  of  a penny  covered  with  a brown  crust  partly , and 
partly  with  a tenacious , fatty  detritus , of  thick  consistence.  It  had  a well- 
defined  border  also. 

On  the  body  there  was  a seemingly  developing  maculous  syphiloid. 
On  the  genitals , I could  detect  nothing  suspicious.  The  inguinal  glands 
were  not  swollen. 

We  began,  immediately,  the  use  of  the  sublimate  injections,  but  it 
could  be  borne  only  in  small  quantities  by  the  sensitive  patient.  But 
the  ulcer  soon  healed  without  leaving  a scar.  The  indolent  submaxil- 
lary glands  were  lessened  also,  but  4 gr.  of  sublimate,  in  about  fifty 
injections,  were  given,  before  a real  change  for  the  better  could  be  seen. 

After  the  treatment  was  completed,  the  patient  felt  perfectly  well  till 
three  weeks  thereafter,  when  he  had  an  epileptiform  attack.  Another 
occurred  about  one  week  later.  During  the  first  attack  much  vomiting 
was  present,  and  attending  the  second  there  was  considerable  diarrhoea. 
When  I saw  the  patient  I detected  on  the  right  cheek  a papulous  infil- 


100 


INDICATIONS  FOR  INJECTION. 


tration  of  the  size  of  a penny,  of  a brown  color  and  medium  soft  con- 
sistence. There  also  was  an  infiltration  of  the  right  upper  eyelid.  On 
the  left  swollen  tonsil  there  were  gray-white  patches,  the  patient  com- 
plained of  a heavy  feeling  in  his  head.  I prescribed  iodide  of  potas- 
sium, because  the  patient  did  not  consent,  then,  to  a repetition  of  the 
hypodermic  injections. 


To  prevent  repetition  of  the  following  material,  I empha- 
size that  in  all  the  six  following  cases  there  were  symptoms 
present  which  I have  characterized,  in  words  preceding  this 
theme,  as  sure  proof  of  infection  by  means  of  the  mucous 
membrane  of  the  mouth. 

The  positive  proof  on  the  lips , the  negative  on  the  genitals , 
and  the  singular  course  of  the  swellings  of  the  lymphatics , 
described  in  extended  detail , were  supported  by  the  most 
accurately  taken  histories . That  the  word  of  the  patients 
themselves  was  only  taken  with  the  greatest  precaution,  is 
self-evident. 

Case  21. — S.,  fifty-four  years  old,  received  under  No.  3293  on  the 
20th  May,  1867. 

The  ulceration  on  the  lip  was  here  accompanied  with  loss  of  sleep, 
headache,  and  buzzing  in  the  ear  ; at  the  same  time  a clearly-defined  poly- 
morphous exanthem  was  present , showing  those  characteristic  pigment  colors , 
remaining  after  a maculous  syphiloid.  There  were  also  papules  and  scales 
besides  a marked  defiuvium  capillorum7  and  angina  condylomatosa . The  use 
of  3 gr.  of  sublimate  was  sufficient  for  a perfect  cure. 

Case  22. — Ch.  H , day  laborer,  twenty-one  years  old,  was  received  as 
No.  2710  on  August  2 2d,  1867. 

Here  also  were  exanthema  maculo-papulosum  defiuvium  capillorum  and 
angina  condylomatosa , and  the  symptoms  of  ulcer  on  the  lips.  Complete 
restoration  was  effected  by  the  use  of  4 gr.  sublimate  hypodermically. 

Case  23. — K.  H.,  laborer,  received  as  No.  3957  on  25th  June,  1868. 

Besides  the  mould-like , broken  and  characteristic  ulcer  on  the  upper  lip7 
there  was  a maculous  syphiloid  and  an  extensive  swelling  of  the  tonsils.  Of 


AFFECTION  OF  THE  MOUTH  AND  PHARYNX.  101 


the  greatly  swollen  submaxillary  glands  one  had  formed  itself  into  an 
abscess . 

Sublimate  injections,  to  the  amount  of  4 gr.,  completely  restored  the 
patient. 

Of  cases  which  concern  women , I have  selected  the  fol- 
lowing three : — 

Case  24. — L.  H.,  a servant  girl,  twenty-five  years  old,  was  received 
into  the  hospital  April  25th,  1867. 

Diagnosis  was  based  in  this  case  on  an  infection  per  os.  There  was  an 
unruptured  hymen  and  a swelling  of  submaxillary  glands , more  extensive  than 
of  the  inguinal. 

The  accompanying  symptoms  were  a papulous  and  maculous  exanthem 
and  superficial  broken-down  condyolmatous  granulations  on  the  labia  majora. 
That  such  may  be  developed  in  the  advanced  progress  of  syphilis,  even 
if  infection  took  place  in  regions  remote  from  the  genitals,  I have 
already  pointed  out. 

Case  25. — Ch.  F.,  servant  girl,  received  April  23d,  1867. 

Examination  revealed  an  intact  hymen. 

Besides  the  characteristic  ulcer  on  the  under  lip  and  large  swellings 
of  the  submaxillary  glands , there  teas  a swelling  also  in  the  axillary  region. 
Along  with  the  already  existing  maculous  and  papulous  exanthemata , there 
was  also  a gummy  swelling  on  the  frontal  bone)  which  disappeared  after  com - 
vletion  of  treatment. 

Treatment  in  this  case  consisted  in  the  use  of  iodide 
of  potassium.  Exact  dates  concerning  the  time  and  amount 
of  treatment  are  wanting  in  our  hospital  journal. 

Case  26. — E.  Sch.,  twenty  years  old,  admitted  at  her  own  request  on 
the  27th  of  April,  1866,  said  that  she  only  once  in  her  life  had  indulged 
in  coitus,  on  March  15th,  1865,  and  her  whole  deportment  verified  her 
assertion.  Her  lover  kissed  her  repeatedly  and  she  remembered  that 
he  had  cracked  lips  ; and  she  noticed  shortly  after  an  ulcer  on  her 
under  lip,  which  disappeared  of  itself.  Subsequently  she  detected  some 
patches  on  her  body  and  a little  later  affection  of  the  genitals. 

Inspection  revealed,  condylomata  lata,  near  the  anus  ; on  the  labia  majora , 

P* 


102 


INDICATIONS  FOR  INJECTION. 


plicas  femorales , tonsils , arac/  at  the  angle  of  the  mouth , muculous  exanthema. 
The  submaxillary  glands  were  very  much)  the  cervical  glands  somewhat , awe? 
tfAe  inguinal  glands  not  at  all  swollen.  The  hymen , with  the  exception  of  a 
small  rent)  was  intact.  Two  and  a half  grains  of  sublimate,  hypodermi- 
cally used,  restored  the  patient  to  health. 

As  we  think  we  have  established  the  occurrence  of  an 
infection  by  the  mouth,  and  especially  by  the  mucous  mem- 
brane, we  can  also  affirm  that  a child  may  convey  the  syphi- 
litic virus  to  a wet  nurse  and  vice  versa . 

I shall  quote  here  a very  remarkable  case, — in  itself 
almost  a unicum, — in  which  a woman  nursing  her  own  child 
was  infected  by  a strange  child,  while  nursing  it,  who  had 
hereditary  syphilis ; afterwards  she  infected  her  own  child. 
Here  the  singular  combination  occurred  that  a strange 
syphilitic  child  infected  a hitherto  healthy  nurse,  producing 
ulcers  from  which  the  healthy  child  was  infected.  The  case 
in  its  further  development  has  still  more  singular  symptoms, 
as,  after  the  woman  had  been  thoroughly  impregnated  with 
syphilis  she  infected  two  men,  of  whom  one  died  on  account 
of  this  disease,  and  the  other  living  was  taken  with  the 
disease  also.  The  woman  furthermore  had  a premature 
delivery  of  a child,  which  very  soon  died. 

A child  from  her  second  marriage  has  completed  its  sixth 
year,  but  it  recently  had  a pustulous  exanthem,  showing 
plainly  the  character  of  syphilis.  Lastly,  the  daughter, 
eighteen  years  old,  who  was  originally  infected  from  the 
breast  and  who  suffered  from  the  same  throat  symptoms  as 
the  mother,  wTas  taken  two  years  ago,  after  she  seemed  com- 
pletely cured  of  the  syphilis,  with  syphilitic  disease  of  the 
bones  and  a lupus. 

The  course  of  this  singular  case  is  almost  similar  to  one 
published  two  hundred  years  ago  by  Sartorius. 


AFFECTION  OF  THE  MOUTH  AND  PHARYNX.  103 


Case  27. — Mrs.  F.,  grocery  keeper,  forty-three  years  of  age,  of  healthy, 
robust  constitution,  good  complexion,  twice  married  and  mother  of  two 
yet  living  children,  was  up  to  her  twenty-fifth  year,  according  to  her 
statement,  perfectly . sound.  She  was  confined  and  nursed  her  own 
child ; but  having  a large  quantity  of  milk,  she  took  a strange  child 
under  her  care,  acting  as  a wet  nurse.  This  child,  as  subsequently 
shown,  came  from  a syphilitic  mother,  and  infected  the  nipples  of  the 
nursing  woman  in  such  a manner,  that  venereal  ulcers  were  developed, 
of  which  she  took  no  notice.  But  her  own  healthy  child  was  infected 
by  nursing  the  breast  and  certainly  per  os.  The  strange  child  died  a 
little  time  afterwards,  notwithstanding  an  antisyphilitic  treatment. 

The  mother  and  her  infected  little  daughter  had  soon  afterwards 
syphilitic  affections  of  the  throat,  which  were  treated  by  the  same  phy- 
sician properly  with  a solution  of  mercury,  and  cured  in  a short  time. 
But  the  husband  becoming  infected  by  his  wife,  had  several  syphiloids, 
afterwards  tophi  on  the  frontal  bones,  and  lastly  an  apopletic  attack, 
in  which  he  died  in  our  hospital. 

Some  time  afterwards  she  married  again  a healthy  man,  although 
she  suffered  from  relapsing  syphilitic  affection,  especially  in  the  throat, 
for  which  she  used,  from  time  to  time,  with  more  or  less  success,  dif- 
ferent antisyphilitic  remedies — as  iodized  mercury,  pills,  inunction, 
Decoctum  Zittmanni , &c. 

She  gave  birth  to  a child  in  the  eighth  month  of  pregnancy,  but  it 
died  in  consequence  of  hereditary  syphilis  after  five  and  a quarter 
months.  Shortly  afterwards  she  was  confined  at  proper  time  with  a 
second  child  yet  living,  aged  seven  years.  The  same  was  healthy  and 
of  plump  appearance  till  the  present,  but  it  now  has  a suspicious 
exanthem. 

The  second  man  was  said  to  have  been  infected  by  the  woman,  but  I 
could  get  no  positive  proof  of  it. 

Eighteen  months  ago  my  esteemed  colleague,  Dr.  Koblank,  had  the 
kindness  to  introduce  this  interesting  family,  and  I have  had  them  for 
demonstration  in  all  my  recent  clinical  lectures.  Seeing  the  patient 
for  the  first  time  I noticed : 

1.  In  the  woman , a thickening  of  both  arcus  glos so -palatini.  The  right 
tonsil  was  atrophied  and  showed  still  existing  superficial  ulceration. 
The  left  was  entirely  gone.  The  posterior  roofs  of  the  palate  were  glued 
on  to  the  posterior  wall  of  the  pharynx  by  a tense  cicatricial  tissue.  The 
same  was  the  case  with  the  soft  palate , which  showed  several  defects.  The 
uvula  was  mostly  destroyed  by  ulceration. 


104 


INDICATIONS  FOR  INJECTION. 


The  consequence  of  this  destruction  and  gluing  process  was,  that  with 
phonation  a clearly  nasal  sound  was  heard , while  a regurgitation  of  the  food 
through  the  nose  occurred  when  eating.  Aside  from  this  the  patient  was 
well. 

2.  The  daughter,  eighteen  years  old,  infected  soon  after  nursing  the  ulcerated 
breasts,  suffered  as  already  said  with  syphilitic  affections  of  the  throat,  which 
were  properly  treated  with  mercury . In  her  sixteenth  year,  fifteen  years  after 
a seemingly  perfect  cure,  a relapse  of  the  affection  took  place.  Tophi  on  the 
frontal  bones  and  on  the  tibia,  were  formed.  They  were  cured,  however,  by 
the  long -continued  use  of  iodide  of  potassium;  but  six  months  afterwards  a 
lupus-like  exanthem  showed  itself  on  the  left  thigh,  which  is  yet  present,  on 
account  of  its  obstinate  resistance  to  a mercury  treatment.  She  married  two 
months  ago. 

The  pharynx  showed  pretty  much  the  same  appearance  as  in  the  mother. 
The  tonsils  were  destroyed  ; the  soft  palate  and  the  posterior  roof  of  the  palate 
were  glued  together,  for  the  most  part,  on  to  the  posterior  wall  of  the  pharynx  ; 
besides  a semilunar  shaped  defect  of  the  epiglottis. 

3.  The  child,  seven  years  old,  by  the  second  husband,  had  a quite 
healthy  appearance  ; but  four  months  ago  it  was  taken  with  & pustulous 
exanthema.  I used  for  it  sublimate  injections,  but  obtained  not  a very 
quick  result.  After  having  used  sixteen  injections,  the  equivalent  of 
1 gr.  sublimate,  they  were  not  wholly  healed,  and  I ordered  iodide  of 
potassium  in  cod-liver  oil,  which  the  patient  still  uses,  without  the 
entire  disappearance  of  the  exanthem. 


V.— SYPHILITIC  AFFECTIONS  OF  THE  LARYNX. 

The  syphilitic  affections  of  the  pharynx  are  followed  by 
those  of  the  larynx , the  same  being  intimately  connected, 
both  topographically  and  anatomically.  The  disease  most 
met  with  here  is  66  syphilitic  catarrh .” 

The  characteristic  symptoms  between  this  and  idiopathic 
catarrh  of  the  larynx,  are  especially : (1.)  The  chronic 
course  ; (2.)  The  dark  red  mucous  membrane  changing  into 
a livid  diffuse  color  of  the  mucous  membrane  ; (3.)  A ten- 
dency to  early  erosions  and  ulcerations. 


SYPHILITIC  AFFECTIONS  OF  THE  LARYNX. 


105 


1.  The  idiopathic  catarrh  of  the  larynx  has  an  acute 
beginning  and  a well-defined  course,  as  in  catching  cold; 
and  therefore  is  very  often  combined  with  catarrh  in  the 
nose,  or  pharyngitis.  The  syphilitic  catarrh  of  the  larynx 
develops  itself  very  slowly , as  do  all  syphilitic  hypermmiae 
and  exudations.  It  very  often  keeps  pace  with  the  develop- 
ment of  the  maculous  syphiloid  of  the  skin. 

2.  The  singular  color  of  the  mucous  membrane  of  the 
larynx,  which  is  dark  red  changing  to  livid,  is  probably  the 
result  of  the  slow  course  of  the  disease.  As  the  maculous 
syphiloid  has  a singular  copper-red  color,  on  account  of  the 
modification  of  the  hyperaemic  clear-red,  produced  during 
the  slow  progress  of  the  disease  by  the  transudation  of  the 
coloring  matter  of  the  blood,  so  the  chronic  progress  of  the 
syphilitic  process  on  the  mucous  membrane  of  the  larynx, 
not  only  gives  rise  to  dilatation  of  the  capillaries,  but  simul- 
taneously here  also,  a transudation  of  the  hmmatine  occurs 
and  a change  in  hue.  The  color  of  the  congested  vocal 
cords  in  common  catarrh  is  a lighter  red,  and  the  dilated 
capillaries,  with  their  small  branches  parallel  to  the  free 
borders  of  the  ligamenta  vocalia,  can  be  clearly  seen. 

But  it  should  never  be  forgotten  here,  as  in  affections  of 
the  pharynx,  that  great  caution  should  be  exercised  in 
making  diagnosis  from  colors. 

3.  As  the  commencement  of  syphilitic  catarrh  generally 
takes  a chronic  course,  it  is  the  more  significant,  that  so 
soon  as  the  inflammation  has  over-reached  the  climax,  the 
formation  of  erosions  through  mollecular  detritus , the  peeling 
off  of  epithelium , and  subsequent  ulcerations  very  rapidly 
occur , — all  of  which  symptoms  come  prominently  into  the 
foreground.  This  quick  destruction  has  a strong  analogy 
to  the  genesis  of  the  plaques  muqueuses  in  the  pharynx. 


106 


INDICATIONS  FOR  INJECTION. 


As  there,  so  in  the  larynx,  where  the  papules,  variously 
situated,  are  swollen  by  a weak  infiltration,  and  which,  in 
the  beginning  producing  in  excess,  an  already  unhealthy, 
unripe  epithelium,  quickly  break  down  and  give  rise  to 
those  gray-white,  dull,  shining  patches,  resembling  places 
cauterized  by  argentum  nitricum . The  epithelium,  de- 
stroyed by  detritus,  and  peeling  off  from  its  place,  leaves 
a superficial  erosion  which,  by  the  manifold  mechanical 
movements,  as  breathing,  talking,  &c.,  induces  still  deeper 
destruction  of  the  underlying  tissue  very  easily. 

As  the  whitish-gray  patches  are  mostly  situated  near  the 
middle  of  the  vocal  cords  in  the  free  borders , more  or  less 
scattered,  we  see,  on  the  other  hand,  that  the  deep  ulcera- 
tions have  a predilection  for  the  region  of  the  processus 
vocalis,  the  Santorin  and  arytenoid  cartilages. 

Another  consequence  of  the  syphilitic  catarrhal  affection 
of  the  larynx  is,  submucous  infiltrations . The  transuded 
fluid  in  catarrhal  parenchymatous  inflammations  is  never  of 
a serous  nature,  but  seems  in  syphilis  to  have  a more  con- 
sistent formation,  and  thereby  produces  quill-like  elevations 
of  a greater  resistance,  with  seldom  well-defined  granulations, 
and  also  tumors  resembling  polypus.  The  natural  conse- 
quence of  these  firm  swellings  are  hoarseness,  and  even 
. aphonia  on  account  of  paralysis  of  the  vocal  cords  induced 
by  pressure  on  the  motor  nerves.  This  I shall  explain  in  a 
following  case  (No.  33). 

But  that  a permanent  stenosis  of  the  larynx  may  be  hereby 
produced,  seems  to  me  only  possible  in  exceptional  cases. 
I,  myself,  have  had  no  occasion  to  observe  it.  The  con- 
dition for  such  a stenosis  of  the  larynx,  which  can  only  exist 
with  the  firmer  infiltrations,  belongs  to  a very  late  period — 
the  gummous  one — and  I cannot  agree  with  Tuerck,  who 


SYPHILITIC  AFFECTIONS  OF  THE  LARYNX. 


107 


designates  such  stenosis  as  a consequence  of  an  early  paren- 
chymatous inflammation. 

It  is  a question  of  importance  whether  condylomatous 
granulations  can  be  produced  in  the  larynx,  as  we  had  occa- 
sion to  see  them  on  different  parts  of  the  skin  and  mucous 
membrane,  more  or  less  extensively,  and  in  a more  or  less 
altered  formation. 

“We  believe  the  same  (broad  condylomes)  to  be  the 
general  cause  of  early  hoarseness  in  syphiliticallv  affected 
patients,  and  also  that  the  accompanying  difficulty  in 
deglutition,  pain  in  the  throat,  &c.,  arise  from  the  same 
source.” 

This  is  the  answer  which  Professor  Gerhardt  of  Jena  and 
Dr.  Roth  have  given  as  the  result  of  nine  months  study  and 
observation,  taken  conjointly  on  the  syphilitic  diseases  of  the 
larynx  from  abundant  material.* 

“ Of  fifty-four  patients  with  secondary  syphilis,  of  whom 
forty-three  were  in  the  earlier  stages,  eight  had  already 
broad  condylomes  in  the  larynx  (15  per  cent.)  and  were, 
most  of  them,  quite  hoarse.  Yes,  one  of  us,  in  another 
hospital,  among  three  syphilitics,  found  broad  condylomes 
in  two  (66 1 per  cent.),  of  whom  one  was  not  even  hoarse.” 

“ The  distribution  of  the  condylomes  in  the  different 
places  in  the  larynx,  was  in  the  following  manner : right 
vocal  cord,  five  times ; left,  three  times ; the  folds  between 
the  arytenoid  cartilages  (base  of  the  larynx),  four  times ; 
anterior  commissure,  once;  aryepiglottic  folds,  twice.” 

Concerning  the  appearance  of  this  so-called  broad  condy- 
lome,  it  is  described  as  follows:  “as  broad,  flat,  quill-shaped 
elevations  ;”  “ red,  like  the  mucous  membrane,  with  the  sur- 
face studded  with  fine  excrescences;”  “of  velvety  appear- 
* Virchow’s  Archives,  vol.  xx.,  p.  482,  and  vol.  xxi.,  p.  1. 


108 


INDICATIONS  FOR  INJECTION. 


ance;,,  “flat,  whitish  drops ;”  “round,  quill-like  elevations 
of  the  size  of  a shot “ protuberances  with  sharp  edges,  of 
the  size  of  a pin-head,  and  white  color.”  In  the  ninth  case, 
first  chapter,  page  12:  “There  were  on  both  vocal  cords, 
behind  the  middle,  (?)  flat,  reddish  protuberances  on  the  free 
border,  and  somewhat  over-reaching  it.  In  spite  of  mercu- 
rial treatment,  these  broad  condylomes  multiplied  themselves 
so  that  the  greater  part  of  the  vocal  cords  on  the  inside  had 
a mulberry-like  appearance.” 

This  examination,  communicated  in  1860,  upon  broad 
condylomes  in  the  larynx,  by  Professor  Gerhardt  and  Dr. 
Roth,  has  been  believed  since  then  by  nearly  all  the  later 
authors  on  syphilis  and  laryngoscopy.  And  I wish  to  ex- 
plain here  that  these  views  and  examinations  of  the  named 
authors  must  consist  of  a real  delusion , and  'particularly  is 
the  described  formation  of  the  excrescences  contrary  to  the 
condylomatous  nature.  The  formation  of  “ flat,  whitish 
drops,”  “sharp-edged  protuberances  of  the  size  of  a pin- 
head,” &c.,  will  not  be  found  in  the  papules  of  the  mucous 
membrane  of  the  larynx.  If,  really,  condylomata  lata  were 
to  be  found  in  the  larynx,  they  would,  like  the  same  on  all  the 
other  mucous  parts  exposed  to  pressure  and  friction,  be  only 
rudimentary,  and  would  very  soon  ulcerate  superficially. 

As,  furthermore,  the  condylomes  belong  to  the  homo- 
geneous tumors  which  are  produced  by  hyperplasia  of  the 
pre-existing  matrix  of  the  papillae,  they  can  only  be  found 
where  the  maternal  soil  is,  i . e.  where  papillae  are  present. 
This  papilla  formation  is  found  on  the  pavement  epithelium , 
but  not  in  the  regions  covered  with  columnar  (flimmer)  epi- 
thelium, as  the  surface  on  the  folds  of  both  “ arytenoid 
cartilages,”  “anterior  commissura  of  the  larynx  wall,”  on 
which  places  Gerhardt  and  Roth  had  found  such  condylomes. 


SYPHILITIC  AFFECTIONS  OF  THE  LARYNX. 


109 


The  pavement  epithelium,  which  extends  from  the  cavity  of 
the  mouth  towards  the  larynx,  reaches  but  a few  lines  above 
its  entrance,  to4  make  room  for  columnar  (flimmer)  epithe- 
lium, consisting  of  long  stretched  cells,  which  are  constantly 
found  on  the  laryngeal  surface  of  the  thyroid  cartilage,  the 
ventricles  of  Morgagni.  Only  a small  strip  of  flattened 
epithelium  descends  from  the  walls  of  the  pharynx  through 
the  incisura  interarytenoidea  and  covers  the  free  borders  of 
the  vocal  cords.  Here  under  this  epithelium  we  find  only 
a few  elevated  papillae,  as  on  the  points  and  the  outer  bor- 
ders of  the  thyroid  cartilages. 

Although  the  named  publications  of  these  two  authors 
appeared  eight  years  ago,  and  although  since  that  time 
laryngoscopy  has  gained  ground,  immensely  and  rapidly, 
and  the  larynx  has  been  the  object  of  many  examinations, 
yet  only  two  authors , according  to  my  knowledge — a very 
insignificant  number — have  published  any  observation  har- 
monizing with  the  above  histological  facts.  The  names  of 
these  authors  are  Vogler  and  Tuerck. 

Dr.  Vogler,*  in  a case  at  Ems,  speaks  of  whitish,  red, 
pointed  drops,  like  excrescences  on  the  border  of  both  vocal 
cords,  which  he  explains  as  condylomatous  granulations, 
without  any  explanation  of  his  view. 

Tuerck  in  his  work,  “ Clinic  of  Diseases  of  the  Larynx 
and  Trachea”  (p.  414),  quotes  in  several  places  “ mucous 
papules  and  granulations  which  are  resembling  each  other 
more  or  less  and  therefore  must  be,  evidently,  of  a syphilitic 
nature,  because  they  exist  with  symptoms  of  constitutional 
syphilis  and  disappear  with  any  anti-syphilitic  treatment.” 

Of  258  cases  published  by  him  we  find  only  seven  which 
really  belong  here.  As  the  seat  of  the  granulations  was  in 

* German  Clinic,  1863,  No.  16. 


110 


INDICATIONS  FOR  INJECTION. 


nearest  proximity  to  ulcers,  it  seems  to  speak  against  their 
syphilitic  nature,  as  it  is  well  known  that  the  here  existing 
so-called  papillary  granulations  can  under  no  consideration 
be  reckoned  among  the  syphilitic  broad  condylomes.  Even 
Gerhardt  is  obliged  to  disavow  it,  and  says  emphatically , 
“that  in  his  cases  there  were  never  ulcerations  present, ” as 
is  the  case  with  granulations  of  the  cellular  tissue  which 
Tuerck  has  already  described. 

An  unbiased  and  exact  analysis  of  Tuerck’s  cases  shows 
that  those  papillary  granulations  and  ulcers,  described  by 
him  as  syphilitic,  must  have  been  in  many  cases  of  a tuber- 
culous nature,  since  in  several  patients  death  is  described  as 
produced  by  tuberculosis. 

What  the  final  result  of  the  mercurial  treatment  was  with 
the  other  patients  of  Tuerck,  cannot  be  at  all  accurately 
stated,  “ on  account  of  the  running  away  of  the  patient 
another  time,  “ from  the  non-appearance  of  the  patient and 
a third  time,  “further  report  was  wanting.” 

Finally,  I have  to  fall  back  on  my  own  observation . It 
may  be  presumed  that  I paid  particular  attention,  in  my 
patients,  to  the  point  in  question.  I have  to  affirm  that  in 
only  three  or  four  patients  did  I find  the  small  protuberances, 
which,  by  only  a superficial  examination,  could  easily  have 
been  confounded  with  the  mucous  membrane  papillae.  I 
never  found  granulations  on  the  vocal  cords  which  could,  in 
the  least,  have  been  regarded  as  condylomata  lata . If  really 
16  per  cent,  of  constitutionally  syphilitic  patients  were  hoarse 
and  the  cause  of  this  hoarseness  was  condylomatous  granula- 
tions of  the  larynx,  as  has  been  the  case  with  Gerhardt’s 
patients,  the  number  of  mine  so  affected  would  be  very 
many. 

I intended  to  thus  dwell  at  length  on  the  laryngoscopic 


SYPHILITIC  AFFECTIONS  OF  THE  LARYNX. 


Ill 


discoveries,  because  they  have  been,  as  already  said,  taken 
as  characteristic,  and  easily  might  lead  into  therapeutical 
errors.  Even  Gerhardt  and  Roth  say  in  their  first  case 
(page  7),  that  only  after  laryngoscopic  examination,  “ the 
suspicion  of  constitutional  syphilis’’  was  well  founded. 

The  other  consequences  of  parenchymatous  inflammation 
of  the  larynx,  which  occur  sometimes  in  the  early  period  of 
syphilis — the  ulcers — have  generally  a greater  difficulty  in 
diagnosis  than  is  usually  supposed. 

But  if,  already,  the  syphilitic  ulcers  on  the  genitals  show 
a certain  modification  concerning  their  configuration,  their 
color,  their  secretion,  their  borders,  &c.,  according  to  their 
different  seats  and  singularity  of  the  affected  tissue,  it  seems 
hazardous  to  speak  about  “ syphilitic  typical  ulcers,”  as  has 
recently  been  done  by  certain  distinguished  German  authors. 
According  to  my  observations,  the  syphilitic  ulcerations  of 
the  larynx,  having  a great  line  of  modification,  may  be  classed 
in  two  general  groups — genetic  and  histologic. 

Concerning  the  genesis  it  is  important  to  bear  in  mind  the 
fact  whether  the  ulcer  originated  from  a syphilitic  catarrhal 
erosion,  or  whether  from  a deeper  inflammatory  infiltration. 

In  a histological  point  of  view , the  ulcers  present  variously 

different  appearances,  according  to  their  locality  in  the  rather 

narrow  cavity  of  the  larynx,  which,  besides  being  made  up 

of  a very  heterogeneous  anatomical  tissue,  as  cartilages, 

muscles,  elastic  fibres,  have  two  different  kinds  of  mucous 

membrane,  with  or  without  glands.  The  functional  activity 

of  some  parts  of  the  larynx  modifies  the  appearances  by 

their  mechanical  workings. 

© 

The  catarrhal  syphilitic  ulcers  appear  on  the  vocal  cords 
mostly  (showing  here  only  flat  ulcerations),  and  their  seem- 
ingly deep  appearance  is  produced  only  by  contrast  with  the 


112 


INDICATIONS  FOR  INJECTION. 


elevation  from  the  swelling  of  the  mucous  membrane  sur- 
rounding. With  deeper  inflammatory  infiltration  of  the 
mucous  membrane,  and  with  ulcers  which  arise  by  destruc- 
tion of  such  infiltration,  the  ulcerative  process,  in  its  further 
extension,  reaches  the  underlying  elastic  tissue  of  the  vocal 
cord,  which  is  much  less  yielding  to  the  erosive  process. 
The  ragged  appearance  that  the  ulcers  assume,  especially 
on  the  free  border,  somewhat  later,  is  probably  caused  by 
the  growing  out  of  several  soft  fibres  which  are  embedded 
between  the  elastic  fibrillae,  that  are  less  susceptible  to 
ulceration. 

When  the  ulcer  has  reached  the  border  of  the  processus 
vocalis,  its  advance  is  less  easy  on  account  of  the  elastic 
fibrillae  being  so  compactly  arranged  -with  the  fibrillated 
original  substance  of  the  reticular  cartilage.  Hindered  from 
further  progress,  the  ulceration  enters  so  much  the  more 
the  nearest  surroundings  of  the  appendages  of  the  vocal 
cords,  and  hereby  produces  in  time,  above  the  organ,  a 
singular  semilunar  cavity  frequently  observed. 

But  after  fully  destroying  these  barriers,  it  may  give  rise 
to  an  entire  uncovering  of  the  cartilages,  and  lastly,  necrosis 
of  the  same,  which  even  may  extend  to  the  posterior  part  of 
several  rings  of  the  trachea.  In  the  last  two  years  I have 
had  two  such  cases  under  my  treatment,  in  which  the  greater 
part  of  the  arytenoid  and  the  whole  Santorin  cartilage  of  the 
left  side  of  the  larynx  were  destroyed  by  necrosis.  Tuerck 
has  also  published  a similar  case. 

In  most  cases  the  stratum  thyreo-arytaenoideum  externum 
of  the  suffering  vocal  cord  is  destroyed,  the  muscles  of  the 
vocal  cord  are  exposed,  and  destruction  must  necessarily 
follow. 

It  is  different  with  the  ulcers  on  the  false  vocal  cords, 


SYPHILITIC  AFFECTIONS  OF  THE  LAHYNX. 


113 


■which  are  rich  in  sebaceous  follicles  and  tissues,  and  allow  a 
gradual  progress  from  the  centre  to  the  periphery,  and  also 
permit  deeper  erosions  in  themselves.  The  soft  and  early 
destroyed  tissue,  which  is  abundant  here,  has  a greater  apti- 
tude for  the  ulcerative  process. 

Very  similar  histological  facts,  as  connected  with  these 
superior  or  false  vocal  cords , we  find  at  that  part  of  the 
epiglottis  which  is  called  petiolus . Consisting  of  net-like 
tissue,  adipose  in  character,  and  a layer  of  acinose  glands, 
the  syphilitic  ulcer  can  extend  in  the  same  manner  as  on  the 
false  vocal  cords,  giving  rise  to  great  loss  of  substance. 

But  we  find  the  syphilitic  ulcers  more  on  the  free  borders 
of  the  epiglottis , than  on  the  petiolus.  These  erosions  seem 
to  have  more  of  a tendency  to  go  deeply,  than  to  remain 
superficially,  and  cause  defects  here,  which,  according  to  my 
observation,  take  the  form  of  circular  segments. 

But  on  no  part  of  the  larynx  have  I seen  more  significant 
ulcers,  than  on  the  epiglottis.  Although  I have  not  ob- 
served perforation  like  Tuerck,  yet  the  destruction  in  many 
cases  was  so  extensive  that  the  whole  epiglottis  was  destroyed , 
only  leaving  a small  residue  appearing  as  if  quilted. 

It  was  singular  that  the  syphilitic  process  never  reached 
over  the  insertion  upon  the  tongue.  The  same  I noticed  in 
other  ulcerations,  especially  of  a carcinomatous  nature. 

Notwithstanding  the  absence  of  the  epiglottis,  which  is 
seemingly  necessary  in  deglutition,  it  is  only  for  a time  that 
fluids  and  solids  occasion  any  difficulty  when  swallowing. 
The  neighboring  organs  induce  closure'  of  the  glottis,  readily 
accommodating  themselves,  so  that  even  fluids,  without 
entering  the  larynx  or  trachea,  could  be  taken  devoid  of  any 
hazard.  For  the  physiological  explanation  of  this  act,  we 

10* 


114 


INDICATIONS  FOR  INJECTION. 


are  indebted  to  the  interesting  observations  of  Professor 
Czermak,  the  inventor  of  the  laryngoscope. 

The  syphilitic  ulcers,  as  above  described,  seem  to  find  in 
their  progress  toward  the  root  of  the  tongue,  a barrier.  On 
the  other  hand,  we  see  it  extend  very  easily  to  the  ligamentum 
ary-epiglottica  and  plicce  glosso-epiglottica , and  witness  de- 
struction frequently  on  account  of  contractility  produced  by 
cicatrization.  It  is  singular  that  such  ulcers  are  very  seldom 
situated  on  the  posterior  wall  of  the  larynx,  where  all  the 
most  favorable  conditions  for  ulcerative  destruction  exist. 

In  phonation,  there  is  the  ever  opening  and  closing  of  the 
glottis,  causing  the  processus  vocalis  to  be  nearer  or  farther 
away ; the  plica  inter-ary tenoidea,  fold-like,  is  flexed  and 
stretched;  and  these  are  the  reasons  why  this  region  of 
mucous  membrane,  covered  with  numerous  glands,  is  found, 
in  common  catarrh,  thickened,  and  in  tuberculosis  ulcerated. 
But  why  syphilis,  especially  here,  causes  so  much  destruc- 
tion, I most  openly  confess  I could  find  no  explanation. 

In  the  important  questions  as  to  the  specific  processes 
occurring  in  the  larynx  in  the  later  stages  of  lues , the  views 
and  observations  of  Virchow  are  decisive.  This  author  has 
not  only  observed,  on  the  inner  surface  of  the  epiglottis,  but 
also  in  the  larynx,  “new  gummous  formations, ” and  asserts 
that  he  could  plainly  trace  them  in  their  various  stages  of 
development.*  But,  with  these  processes,  the  condyloma- 
tous  granulations  on  the  mucous  membrane  cannot  be  classed, 
as  described  by  Gerhardt  and  Both.  I need  not  further 
emphasize  here,  for,  .according  to  the  testimony  of  these 
authors  themselves,  the  appearances  were  in  the*  primary 
stadium  of  syphilis.  And  I think  I have  shown  above, 
pretty  clearly,  that  such  formations  do  not  exist  here. 

* German  Clinic,  1860,  No.  48,  Malignant  Tumors,  vol.  II.,  p.  413. 


SYPHILITIC  AFFECTIONS  OF  THE  LARYNX. 


115 


But  on  the  other  hand,  44  the  two  laryngoscopically  ob- 
served knotty  swellings  in  the  larynx  of  two  syphilitic 
women,”*  might  be  classed  among  46  gummy  knots,”  and 
for  this  reason,  since  they  were  complicated  with  ulcerations 
of  the  pharynx  and  knotty  affection  of  the  skin  upon  the 
nose,  as  well  as  in  other  regions  of  the  body. 

Why  Tuerck  f should  especially  designate  these  two  ob- 
servations of  Grerhardt  and  Both  44  as  unwarrantable,”  I 
really  do  not  know,  since  he,  himself,  publishes  cases  where 
a want  of  complications  and  appearance  of  the  excrescences, 
has  certainly  no  bearing  whatever  on  their  gummy  character. 
He,  himself,  is  forced,  by  an  interrogation  set  after  the 
expression  44 gumma,”  to  doubt  one  of  his  cases;  and,  too, 
it  is  significant  that  in  the  second  of  his  cases,  the  so-called 
syphilitic  tumor  44  gave  way”  to  an  ordinary  treatment. 

I had  a large  number  of  syphilitic  patients  under  my 
treatment  in  whom  circumscribed  tumors  on  the  different 
parts  of  the  larynx  were  present , but,  that  they  were,  in 
reality,  gummy  knots,  neither  the  appearance  nor  other 
diagnostic  signs  would  warrant  the  assertion;  yet  still,  the 
gummous  character  of  the  diffuse  infiltration  was  very 
striking . They  were  seated  on  the  epiglottis,  and  on  the 
posterior  wall  of  the  larynx,  the  chordae  vocales  and  false 
vocal  cords.  Their  color  was  a dirty  yellow-red,  and  their 
consistency,  as  ascertained  by  digital  examination,  on  the 
epiglottis  and  false  vocal  cords,  somewhat  elastic.  The 
ulcers  either  were  deeply  seated  in  the  tissues  or  ran  along 
superficially.  After  healing,  the  infiltrations  remained  in 
an  obstinate  manner,  causing  here  stenosis  of  the  larynx,  as 
I shall  further  describe. 

Differential  diagnosis  of  tertiary  ulcers  from  scrofulosa , 
* Ch.  I.,  pp.  23,  24.  f Ch.  I.,  p.  388. 


116 


INDICATIONS  FOR  INJECTION. 


or  lupus , is,  as  every  experienced  clinicist  well  knows,  very 
difficult ; especially  so  to  distinguish  the  latter  from  specific 
syphilis , either  in  the  larynx  or  pharynx.  I found  par- 
ticularly with  those  patients  who  have  been  sent  to  me  from 
Poland  and  Russia,  lupous  ulcerations  in  the  above-named 
organs,  which  could  not  be  classed  among  the  syphilitic 
because  they  appeared  in  such  young  persons  that  there 
was  no  possibility  of  infection,  and  even  the  accurate  exami- 
nation of  the  parents  excluded  a possibility  of  a hereditary 
taint . 

The  distinction  of  tuberculous  ulcers  is  more  easy,  not 
only  on  account  of  their  less  characteristic  condition,  which 
is  apparent  to  the  eye,  but  also  the  condition  of  the  lung, 
which  is  here  decisive.  If  tuberculosis  has  already  caused 
deep-seated  destruction  in  the  cartilaginous  tissue  of  the 
larynx,  we  may  be  sure  that  in  the  softer  and  more  easily 
broken  down  parenchyma  of  the  lung,  greater  destruction, 
especially  vomicce , must  be  present,  and  be  certainly  revealed 
by  auscultation  and  percussion. 

The  therapeutics  of  the  diseases  of  the  larynx , is  divided, 
as  in  the  pharynx , into  a general  and  local  one . As  to  the 
former,  the  lighter  processes,  consisting  of  hyperaemia,  weak 
exudations  and  erosions,  heal  on  an  average  very  quickly  and 
readily,  after  using  by  injection  J gr.  or  more  of  the  sublimate. 
For  ulcerations  already  existing,  larger  doses  from  1 J gr.  to 
2 gr.  are  necessary.  But  more  rebellious  are  the  so-called 
tertiary  processes,  where  the  already  gummous  granulations 
and  tumors  are  formed,  or  have  advanced  to  ulceration,  and 
where  the  cartilaginous  tissue  of  the  larynx,  and  the  osteoides 
of  the  pharynx,  are  involved.  Iodide  of  potassium , as  is 
well  understood,  has  a curative  effect  and  may  sometimes  be 
used  in  these  affections. 


SYPHILITIC  AFFECTIONS  OF  THE  LARYNX. 


117 


According  to  my  observations,  injections  of  sublimate  are 
indicated  in  the  following  cases  : — 

1.  If  iodide  of  potassium  has  been  used  for  a certain  space 
of  time  without  any  material  benefit. 

2.  If  after  an  apparent  cure  from  the  use  of  iodide  of 
potassium,  syphilis  reappears,  showing  its  latent  disposition. 

3.  If  periculum  in  mora , or  danger  of  fatal  stenosis, 
appear. 

4.  If  the  ulcers  are  situated  on  those  parts,  whose  full 
integrity  is  absolutely  necessary  for  the  normal  function  of 
the  affected  organ,  the  destruction  of  which  may  easily 
occur,  e.  g.  the  vocal  cords. 

The  quantity  to  be  used  in  these  cases  is  quite  different- — 
sometimes  2 gr.  will  be  sufficient,  and  again  greater  quanti- 
ties, even' up  to  5 gr.,  maybe  necessary. 

But  if  defects  should  still  remain  on  the  cartilaginous 
parts  of  the  larynx,  or  on  the  bone  of  the  palatum  durum, 
after  all  other  symptoms  caused  by  syphilis  have  disappeared, 
it  is  best  not  to  force  a cure  by  further  injections. 

To  help  granulation,  a more  strengthening  treatment  is 
necessary  than  the  sublimate , which  is  hurtful  to  the  protein, 
since  these  places  are  so  poorly  supplied  with  vessels,  and 
nutrition  is  in  consequence  here  materially  impaired. 

Local  therapeutics  here  is  very  necessary.  With  a forced 
internal  or  external  use  of  mercury  a cure  can  never  be 
established,  but  the  destructive  process  will  rather  be  favored. 
We  must  concede  that  local  treatment  plays,  very  often  in 
these  affections,  quite  an  important  part.  Though  super- 
ficial erosions  sometimes  may  disappear  of  themselves,  still 
their  cure  may  be  hastened  by  pencilling  with  argentum 
nitricum.  This  is  quite  indispensable  in  ulcerations.  Only 
in  cases  where  either  the  attending  physician,  from  lack  of 


118 


INDICATIONS  FOR  INJECTION. 


dexterity,  is  unable  to  use  argentum  nitricum,  or  where  the 
seat  of  the  ulcer  is  difficult  to  reach,  or  where  finally,  the 
patient  shows  a great  hypermsthesia  against  the  argentum 
nitricum,  which  is  very  seldom  the  fact,  would  I recommend 
the  atomizer , either  charged  with  this  named  caustic  in  solu- 
tion, or  with  the  sublimate ; of  the  strength  of  the  former, 
5 gr.  to  10  gr.  to  100  parts  of  water,  or  the  latter  even 
stronger.  The  patient  must  not  inspire  too  deeply,  because 
medication  ought  to  reach  the  larynx  and  not  the  trachea 
and  bronchi.  Concerning  the  prevalence  of  the  diseases  of 
the  larynx  in  constitutional  syphilis,  there  were  out  of  1000 
patients,  forty-four  persons,  or  4J  per  cent.,  who  were  more 
or  less  affected  with  hoarseness,  a result  quite  in  contrast 
with  the  already  mentioned  high  percentage  of  Gerhardt 
and  Roth. 

The  following  cases  have  a double  purpose — to  serve  as 
paradigma  for  the  different  formations  in  laryngeal  disease, 
and  to  illustrate  the  extent  and  effects  of  subcutaneous 
medication. 

The  first  case  shows  how  needful  an  examination  of  the 
larynx  is  in  all  persons  suffering  with  syphilis,  even  when 
not  complaining  of  pain  in  that  locality. 

Case  28. — Clara  T.,  twenty-five  years  old,  of  weak  constitution  and. 
flabby  muscles,  suffered  from  her  earliest  childhood  from  bone  affec- 
tions, which  had  their  painful  seat  in  both  elbow  joints,  and  which  are, 
in  consequence  of  caries,  yet  very  much  anchylosed.  In  her  nineteenth 
year  she  was  infected  for  the  first  time,  and  received  in  1863  into  our 
hospital.  Being  discharged  after  some  time,  she  returned  again  in 
the  year  1865,  Both  times  she  suffered  from  vaginal  catarrh  and 
pointed  condylomes.  Treatment  both  times  was  a local  one. 

In  the  following  year  and  till  the  end  of  1868  she  was  treated  four 
times  for  syphilis — the  third  time  for  broad  condylomes  situated  on  the 
labia  majora.  They  subsided  after  treatment  for  five  weeks  with  the 


SYPHILITIC  AFFECTIONS  OF  THE  LARYNX. 


119 


11  sarsaparilla  sweat  cure.”  She  soon  returned  to  our  wards,  and  there 
was  not  only  a relapse  of  the  condylomes,  but  on  both  tonsils  deep 
ulcerations  were  found.  At  the  same  time  there  was  a knotty  syphiloid 
on  several  places  on  the  back  and  left  forearm,  being  only  partly  ulcer- 
ated. After  using  1 gr.  of  sublimate  and  f gr.  iodide  of  mercury  hypo- 
dermically, restoration  was  effected. 

After  repeatedly  returning  to  our  hospital  with  nothing  but  primary 
and  local  symptoms,  she  was  again  admitted,  March  1st,  1869,  for  the 
seventh  time.  Besides  a superficial  erosion  nothing  marked  was  found 
on  the  genitals.  But  the  cicatrices  which  remained  from  the  already 
mentioned  “ knotty  syphiloids,”  showed  on  their  periphery  a dirty 
reddish  color,  and  occasionally  small  papules  of  the  size  of  a pea, 
covered  with  scales,  which  gave  rise  to  the  suspicion  that  syphilis  was 
not  wholly  eradicated  from  the  system,  and  therefore  we  searched  for 
something  more  tangible  and  local  on  other  organs. 

The  glands  on  the  different  parts  of  the  body  were  only  slightly 
swollen.  Examination  of  the  pharynx  revealed  a certainly  already 
longer  existing  defect  of  the  tonsils,  and  thickening  of  the  roofs  of  the 
palate. 

Laryngoscopic  inspection  of  the  patient,  who  complained  neither  of  pain 
in  the  throat  nor  of  hoarseness,  showed,  besides  a large  swelling  of  the  seba- 
ceous follicles  of  the  root  of  the  tongue,  a broad  ulcer,  four  to  six  lines  long, 
on  the  free  border  of  the  epiglottis , reaching  towards  the  left  ligamentum 
glosso-epiglotticum,  and  having  sharply  defined  edges,  which  were  surrounded 
by  broad  cherry -red  borders . On  the  surface  of  the  ulcers,  was  a dirty, 
yellow,  firm  coating. 

Cod-liver  oil  with  an  addition  of  iodide  of  potassium  and  iodine  were 
used ; but,  as  this  medication  caused  but  slow  progress,  subcutaneous 
injections  of  sublimate  were  ordered. 

This  caused  not  only  a quick  cicatrization  of  the  ulcer  of  the  larynx, 
but  also  a complete  healing  of  the  papulous  and  squamous  exanthemata, 
so  that  3 gr.  of  sublimate  in  all  were  sufficient  for  a complete  cure. 

Of  a large  number  of  cases  of  affections  of  the  larynx,  I 
shall  only  give  the  following  ones,  embodying  important 
symptoms  : 

Case  29. — Otto  L.,  received  into  the  hospital  May  16,  1868,  and  was 
as  follows  : 


120 


INDICATIONS  FOR  INJECTION. 


Hard  ulcer  on  the  inner  fold  of  the  prepuce,  erosions  on  the  upper 
lip  and  left  arcum  glosso-palatinum.  The  cause  of  an  existing  hoarse- 
ness was  from  a swelling  of  both  vocal  cords , on  which  were  long  gray-white 
colored  patches,  parallel  to  the  free  border . There  was  a small  loss  of  sub- 
stance of  the  upper  third  of  the  left  vocal  cord , which  was  quite  visible , with 
the  closure  of  the  glottis  during  phonation.  There  was  a redness  and  slight 
swelling  of  the  mucosa , epiglottis , false  vocal  cords  ; greater  swelling  of  the 
left  ligamehtum  glosso-epiglotticum ; besides  superficial  erosions  of  some  of 
the  swelled  sebaceous  follicles  of  the  tongue.  At  the  same  time , gray -white 
pea-like  ulcers  could  be  seen  on  the  soft  and  hard  palate. 

Only  after  the  fourteenth  injection,  amounting  in  all  to  If  gr.  of  sub- 
limate, was  a change  for  the  better  visible.  The  restoration  advanced 
with  steady  progress ; so  that  he  was  discharged  cured  at  the  end  of 
two  weeks,  after  having  used  2J  grs.  of  sublimate. 

Case  30—  Anna  P.,  maid-servant,  twenty-five  years  old ; from  a good 
family,  and  healthy  constitution ; had  already  been  treated,  and  quite 
often,  with  the  sarsaparilla  sweat  cure,  for  broad  condylomes  on  the 
labia  minora  and  majora,  maculous  exanthema,  and  for  superficial  ulcer- 
ation at  the  corner  of  the  mouth. 

She  was  received  again  April  2,  1868,  into  the  Charite.  She  had 
large  condylomata  lata  at  the  pudenda  and  around  the  anus,  maculous 
exanthema,  loss  of  hair,  urethritis,  purulent  vaginal  discharge,  condy- 
lomatous  angina  tonsillaris,  glandular  swellings  and  hoarseness.  La- 
ryngoscopic  inspection  revealed  the  cause  of  the  hoarseness  to  be  gray- 
ish-white patches  on  the  epithelial  covering  of  the  reddened  and  somewhat 
swollen  vocal  cords  ; also  on  the  false  vocal  cords  and  on  the  arytenoid  cartil- 
age similar  patches  could  be  seen.  On  the  tongue , around  the  papillse  cir - 
cumvallatse , excrescences  of  a round , pea - like  size  were  visible.  The  sebaceous 
follicles  of  the  root  of  the  tongue  were  greatly  swollen  and  of  a gray-white 
color . 

I prescribed  injections  of  sublimate.  At  first  the  hoarseness  in- 
creased, and  a second  examination  with  the  laryngoscope  revealed 
small  erosions  on  the  vocal  cords,  especially  at  the  places  where  the 
grayish-white  patches  were  seen.  But  very  soon  the  treatment  was 
successful ; so  that,  after  the  hypodermic  use  of  2J  grs.  of  sublimate, 
the  laryngeal  affections  and  the  other  syphilitic  appearances  disap- 
peared. The  glands,  however,  did  not  return  to  their  original  size. 

Case  31. — B.,  forty-five  years  old,  from  healthy  parentage  and  of 


SYPHILITIC  AFFECTIONS  OF  THE  LARYNX. 


121 


robust  constitution ; large  panniculus  adiposus ; lias  suffered  several 
years,  more  or  less,  with  renal  calculus,  for  which  he  has  used,  with 
more  or  less  benefit,  the  Carlsbad  water.  During  the  last  treatment  he 
experienced  hoarseness  and  painful  deglutition.  Professor  Botkin,  of 
St.  Petersburg,  was  consulted,  and  he  diagnosed  at  once  syphilis,  and 
sent  the  patient  to  me. 

I saw  the  patient  the  first  time  in  August,  1867,  and  found,  besides 
the  lymphatic  glands  of  the  submaxillary  region  swollen,  only  a few 
remaining  scales,  covered  with  thickened  epidermis  on  the  palms  of 
both  hands.  Inquiry  elicited  that  infection  took  place  six  months  pre- 
viously. Laryngoscopic  inspection  confirmed  the  existence  of  syphilis 
in  the  larynx,  which  was  suspected  by  Professor  Botkin.  In  the  middle 
of  the  free  border  of  the  epiglottis  there  was  a crescent- shaped  loss  of  sub- 
stance!,  besides  an  ulcer  of  the  size  of  a bean , deep-seated  and  situated  on  the 
left  thyroid  cartilage.  It  seemed  to  be  still  developing.  Thick  pus  covered 
its  base. 

We  used  energetically  subcutaneous  injections,  in  doses  varying  from 
J gr.  to  gr.  of  sublimate.  After  using  three  grains  altogether,  there 
was  not  only  no  change  for  the  better,  but,  on  the  contrary,  the  ulcera- 
tions had  spread  further  and  a violent  cough  had  set  in.  Professor 
Virchow  was  consulted,  and  he  discountenanced  the  arising  suspicion 
of  the  tuberculous  character  of  the  ulcer ; so  that  the  same  treatment 
was  continued,  and  after  using  2J  grs.  more  of  the  sublimate,  entire 
recovery  was  effected. 

Now,  after  an  elapse  of  eighteen  months,  the  patient  is  perfectly  well. 

Case  32. — Agnes  F.,  twenty-three  years  old,  of  delicate  and  sickly 
appearance,  and  emaciated ; suffered  in  her  childhood  with  scrofulosis, 
especially  in  the  glands  of  the  cervical  region,  which  formed  into  ab- 
scesses, where  clear  traces  of  cicatrization  are  plainly  visible. 

When  twenty-one  years  old,  she  was  first  received  into  the  Charite 
Hospital,  suffering  with  broad  eroded  condylomes  on  the  labia  majora 
and  minora.  The  right  tonsils  were  also  ulcerated,  and  on  the  body 
there  was  a maculous  and  papulous  exanthema.  After  thirteen  injec- 
tions, consisting  of  2\  grs.  of  sublimate,  she  was  discharged  cured.  In 
October  of  the  same  year  a relapse  occurred,  taking  the  form  of  broad 
condylomes  on  the  labia  majora  and  small  impetiginous  incrustations 
in  the  neighborhood  of  the  glutaei. 

She  was  again  discharged,  after  the  further  use  of  2J  grs.,  only  as 
seemingly  cured.  After  the  expiration  of  eight  months,  she  was  again 

a 


122 


INDICATIONS  FOB  INJECTION, 


compelled  to  seek  relief  at  the  hospital.  She  suffered  not  only  with 
broad  condylomes  this  time,  but  also  with  throat  affections.  On  the 
anterior  part  of  the  left  palate-roof  there  was  a long,  flat  and  large  ulcer , 
which  was  covered  with  a grayish-yellow , firm , adherent  coating.  Both  ton- 
sils were  swollen  and  red.  On  the  right  tonsil  there  were  small  yellow  ulcers 
and  very  similar  ones  were  to  be  found  on  the  false  vocal  cords , on  the  left  lig - 
amentum  ary epiglotticum , and  on  the  left  arytenoid  cartilage.  Everywhere 
the  ulceratious  showed  a superficial  course , resembling  more  diphtheritic  than 
syphilitic  ulcers.  Notwithstanding  the  lack  of  a sure  diagnosis,  and  the 
emaciated  condition  of  the  patient,  I used  the  subcutaneous  medication. 
Hardly  were  lj  gr.  of  the  sublimate  used  before  cicatrization  of  the 
borders  of  the  ulcers  began,  and  complete  healing  with  2J  grs.  was 
brought  about. 

Case  33. — The  following  case  may  serve  as  an  example  of  paralysis 
of  the  vocal  cords,  in  consequence  of  syphilitic  infiltration,  and  a quick 
restoration  to  health  by  the  use  of  sublimate,  subcutaneously  adminis- 
tered : 

F.  C.,  a merchant,  of  a healthy  family  and  healthy  appearance,  aged 
twenty-three ; says  he  never  suffered  from  throat  affections,  nor  syphil- 
itic disease.  During  the  last  several  years,  at  intervals,  he  has  been 
attacked  with  furunculosis.  Further  investigation  revealed  that  two 
months  previously  the  patient  contracted  gonorrhoea,  which  was  neither 
lasting  nor  painful.  Other  symptoms,  which  might  follow  a chancre  in 
the  urethra,  were  not  present.  His  hoarseness  dated  back  for  only  a 
fortnight,  gradually  becoming  more  intense,  dyspnoea  existing  for  the 
last  two  days  only.  When  I saw  the  patient  the  first  time,  I was  some- 
what astonished  at  the  extreme  hoarseness  and  that  the  respiratory 
murmur  had  mixed  with  it  a certain  degree  of  stridor.  Examination 
revealed  a maculous  syphiloid  that  was  very  marked  on  the  trunk,  be- 
sides swelling  of  the  inguinal,  cervical  and  submaxillary  glands.  The 
pharynx,  tonsils  and  palate-roofs  were  swollen,  and  the  first  especially 
was  covered  with  the  already  described  grayish-white  and  somewhat 
elevated  plaques. 

The  laryngoscopic  examination  was  very  interesting . Aside  from  the  sus- 
picious redness  of  the  larynx , there  was  an  important  swelling  of  the  vocal 
cords , with  a diminished  ability  for  movement , as  in  paralysis.  The  glottis 
was  of  a sharp , triangular  shape.  In  quiet  respiration  the  swollen  vocal 
cords  touched  themselves  on  the  anterior  corner , wholly  occluding  the  pars 
ligamentosa  and  the  pars  cartilaginea , so  that  a fissure  showed  itself  , about 


SYPHILITIC  AFFECTIONS  OF  THE  LARYNX.  123 


four  or  five  millimeters  in  length.  In  forced  inspiration  and  expiration  the 
opening  as  well  as  the  approaching  of  the  vocal  cords  was  hardly  perceptible. 
The  same  immobility  was  present  during  intonation , while  the  false  vocal  cords 
very  nearly  approached  each  other  in  the  first  act  of  phonation. 

These  symptoms,  together  with  a marked  defluvium  capillorum,  in- 
duced me  to  base  my  diagnosis  as  syphilis,  taking  the  paralysis  of  the 
ligamenta  vocalia  as  a consequence  of  pressure,  produced  by  syphilitic 
infiltration,  upon  the  motor  nerves  of  the  vocal  cords.  The  result  of 
the  treatment  justified  this  diagnosis  ; for  after  the  use  of  2J  grs.  of 
sublimate,  given  subcutaneously,  the  patient  was  discharged  as  cured. 

After  ten  injections,  the  movements  of  the  vocal  cords  were  more 
perceptible  ; but  as  the  redness  did  not  wholly  disappear,  local  reme- 
dies were  used  for  it. 

The  following  cases  show  that  with  affections  of  the  larynx 
an  energetic  treatment  is  necessary  in  the  beginning,  because 
a loss  of  substance  of  the  vocal  cords  may  easily  occur,  in- 
ducing an  alteration  in  the  voice  which  cannot  be  remedied 
by  later  administration  of  strong  subcutaneous  injections. 

Case  34. — K.,  brewer  by  trade,  twenty  years  old,  of  healthy  consti- 
tution, received  into  the  Charite,  June  14,  1868,  patient  No.  3196,  had 
on  the  prepuce  sharp,  circumscribed,  hard,  superficial  erosions,  swelling 
of  the  inguinal,  and  especially  of  the  submaxillary  glands,  and  consider- 
able hoarseness.  Laryngoscopic-  inspection  revealed  an  ulcer  four  to 
five  lines  long,  very  deeply  situated,  sparingly  covered  with  pus,  together 
with  superficial  erosions  of  the  right  swelled  vocal  cord.  Also  the 
posterior  wall  of  the  larynx  was  swollen,  and  had  a milky  hue  of 
epithelial  covering.  The  epiglottis  seemed  to  be  thickened,  and  had  on 
its  free  borders  a few  yellow  spots  which  could  be  distinguished  either 
as  fatty  follicles,  or  as  a small  submucous  layer  of  pus.  The  swollen 
false  vocal  cords  showed  also  similar  appearances.  Besides  thislarjmgeal 
condition,  the  whole  body  was  covered  with  but  a slight  maculous 
syphiloid.  Inquiry  revealed  that  infection  took  place  about  twelve 
weeks  before,  and  the  syphilitic  sclerosis  quickly  caused  phyinosis, 
which  had  been  operated  on  eight  weeks  ago. 

After  the  use  of  2 gr.  of  sublimate  hypodermically,  the  epithelial 
erosions  disappeared,  and  the  ulcer  on  the  vocal  cords  healed,  but  the 


124 


INDICATIONS  FOR  INJECTION. 


loss  of  substance,  and  cicatrization  caused  thereby,  left  the  hoarseness 
remaining. 

Case  35. — Mrs.  V.,  thirty-six  years  old,  of  robust  build,  but  of  un- 
healthy, pale  color  ; was,  up  to  her  twenty-fourth  year,  quite  well.  Three 
weeks  after  marriage  she  became  sore  at  the  genitals,  and  a little  while 
later  wart-like  excrescences  with  well  defined  edges  appeared.  It  seems 
also  that  the  patient  suffered  from  broad  condylomes.  She  used  iodide 
of  potassium  and  Russian  vapor  baths,  with  seemingly  a curative  result, 
but  some  weakness  remained.  After  eight  years  a throat  affection  made 
its  appearance  characterized  by  a hoarseness  and  pain  in  deglutition. 
The  same  therapeutics  were  repeated  with  similar  results.  After  the 
lapse  of  three  years  more,  the  throat  difficulties  reappeared,  but  in  a 
different  way,  causing  complete  aphonia.  Decoctum  Zittmanni,  with 
inunction  treatment,  was  employed.  But  in  a year  these  symptoms  ap- 
peared again.  Sixty-four  bottles  of  Decoctum  Zittmanni  were  used, 
but  without  any  very  favorable  result,  as  the  aphonic  voice  yet  remained. 
It  is  mentionable  that  during  these  twelve  years  of  married  life,  she  had 
never  given  birth  to  a living  child,  but  on  the  contrary  she  had  aborted 
every  year,  and  always  in  the  third  month,  the  last  time  being  one 
year  ago. 

November,  1868,  the  patient  commenced  treatment  with  me.  I found 
on  the  left  tonsil  a small  ulceration , swelling  of  the  right  vocal  cord  and  a 
very  great  loss  of  substance  of  the  left  one)  reaching  from  the  middle  to  the 
processus  vocalis. 

I used  with  the  patient  the  injection  treatment.  Already,  after  using 
but  If  gr.  of  sublimate,  the  swelling  of  the  right  vocal  cord  was  less- 
ened and  the  ulcerations  were  cicatrized,  but  the  aphonia  caused  by 
the  contractility  of  the  cicatrice  was  not  very  materially  altered. 

Case  36. — Lieut.  S.,  thirty  years  old,  of  healthy  constitution  and  ap- 
pearance ; had  always  enjoyed  good  health.  January,  1867,  he  was 
infected.  On  the  prepuce  an  ulcer  appeared,  which  was  designated  by 
his  attending  physician  as  u ulcus  molle,”  and  he  was  treated  only 
locally  this  first  time.  But  seven  weeks  later,  a throat  affection  ap- 
peared, for  which  gargarisms  were  used.  The  physician  in  attendance 
denied  the  existence  of  any  syphilitic  affection. 

Shortly  afterwards,  about  nine  weeks  from  the  time  of  the  suspicious 
coitus,  a maculous  exanthem  appeared.  Another  physician  was 
brought  into  consultation,  who  called  the  exanthem  a syphilitic  erup- 

i 


SYPHILITIC  AFFECTIONS  OF  THE  LARYNX. 


125 


tion,  and  detected  a yet  existing  induration  on  the  prepuce.  Dzondi’s 
treatment  was  ordered,  and  one  hundred  and  eighty  pills  taken,  besides 
sarsaparilla  tea.  But  the  results  were  not  lasting.  Painful  deglutition 
and  hoarseness  appeared  again,  and  the  patient  used  for  six  weeks  de- 
coctum  Zittmanni.  Even  the  effects  of  this  were  but  temporary,  and 
relapse  occurred  again  after  three  months.  Iodide  of  potassium  was 
prescribed  in  larger  doses,  and  twenty-five  drachms  were  used.  The 
disease  of  the  pharynx  disappeared,  but  hoarseness  remained. 

April,  1868,  the  patient  began  treatment  with  me.  Both  tonsils  swol- 
len ; the  right  grown  together  with  the  anterior  roof  of  the  palate.  The 
velum  and  posterior  wall  of  the  pharynx  were  very  much  reddened,  and 
the  latter,  especially,  interspersed  with  white  capillaries.  On  the  free 
border  of  the  palatum  molle , left  from  the  appendage  of  the  uvula , there  was 
an  ulceration  of  the  size  of  a bean , which  was  dispersed  through  all  the  tissue , 
encircled  by  a cherry-red  colored  border , and  covered  with  a grayish-white 
pus-like  secretion.  Similar  extensive  ulcerations  were  seated  on  the  anterior 
border  of  the  left  arytenoid  cartilage , and  on  the  right  vocal  cord.  On  the 
latter , one  ulcer  occupied  three-fourths  of  the  processus  vocalis ^ of  which 
already  a small  part  was  destroyed.  In  phonation  this  defect  of  the  glottis 
was  more  visible.  On  the  left  swelled  vocal  cord  only  superficial  erosions  could 
be  detected. 

Besides  swelling  of  the  cervical  and  submaxillary  glands,  I could  not 
detect  any  further  complication  of  syphilis ; I instituted  a local  and 
subcutaneous  treatment,  and  after  the  use  of  only  lj  gr.  of  sublimate, 
already  all  the  ulcers  of  the  larynx  and  pharynx  disappeared,  and  also 
the  raucedo  syphilitica  was  mostly  gone.  Patient  thought  he  was  com- 
pletely cured ; caught  cold,  and  the  hoarseness  increased,  as  a conse- 
quence. Laryngoscopic  inspection  revealed,  this  time,  great  swelling  of 
both  vocal  cords , and  a new  ulceration  of  the  size  of  a pinhead , above  the  cir- 
cumscribed loss  of  substance  on  the  right  appendages  of  the  vocal  cords.  We 
began  again  to  inject  the  sublimate  solution,  and  it  required  the  further 
amount  of  2 gr.  to  effect  perfect  restoration. 

But  after  a complete  cure,  a raw  and  somewhat  hoarse  sound  of  the 
voice  remained,  resulting  from  the  retraction  of  the  cicatrized  tissue 
above  the  processus  vocalis  of  the  right  vocal  cord,  and  thus  bringing 
about  an  insufficient  closure  of  the  glottis. 

In  the  following  case,  the  sublimate  injection  w~as  used 
with  good  result,  for  ulceration  in  the  larynx,  but  probably 

li* 


126 


INDICATIONS  FOR  INJECTION. 


interruption  caused  the  later  arising  stenosis  of  the  larynx, 
which  produced  so  much  dyspnoea  even  impending  suffocation, 
that  tracheotomy  had  to  be  performed. 

Case  37. — Mrs.  B.,  thirty-eight  years  old,  mother  of  a seven  years  old, 
healthy  child ; married  about  twelve  years  ago  ; was  taken  in  December, 
1865,  with  painful  deglutition  and  cough.  Two  physicians  examined 
her,  and  declared  her  to  be  suffering  from  tuberculosis.  The  treatment 
being  of  no  avail,  a third  physician  was  consulted.  He  declared  her 
disease  to  be  syphilis,  and  prescribed  a mercurial  treatment,  followed 
by  iodide  of  potassium.  But,  as  the  patient  got  no  better,  she  was  sent 
to  our  hospital. 

Status prsesens  March  21,  1868. — Patient  is  pale  and  cachectic;  exami- 
nation of  the  genitals  reveals  only  oedematous  swelling  of  the  labia 
majora  and  superficial  erosions  of  the  swollen  mouth  of  the  womb.  In- 
spection of  the  phrynx  shows  the  right  arcus  palato-pharyngeus  to  be 
changed  into  broad  and  almost  transparent  fibres  ; the  left  partly  grown 
together  with  the  posterior  wall  of  the  pharynx.  The  place  of  this  growth 
exhibits  a longitudinal  ulcer,  with  papulous  granulations  in  the  sur- 
roundings. No  trace  is  left  of  either  tonsil.  In  both  pits,  where 
formerly  the  tonsils  were,  which  are  enlarged  by  the  mentioned  flexion 
of  the  arches,  the  mucous  membrane  is  covered  with  superficial  erosion. 
But  very  little  of  the  uvula  is  remaining,  it  now  having  a conical  shape. 
Above  the  same  there  is  a scarred  centre  from  which  fibrous  stripes 
radiate. 

Rhinoscopic  examination  is  only  partly  admissible,  and  reveals  super- 
ficial ulcerations  of  the  posterior  part  of  the  soft  palate,  and  a swelling 
of  the  mucous  membrane,  reaching  high  up  into  the  cavum  pharyngo- 
nasale. 

The  papillae  circumvallatae  of  the  tongue  are  small  and  very  difficult 
to  distinguish.  In  examining  with  the  finger  around  the  root  of  the 
tongue,  we  find  an  atrophy  of  the  sebaceous  glands,  producing  here  a 
singular  smoothness.  In  passing  the  finger  further  along,  we  feel  in 
place  of  the  epiglottis  a very  hard,  narrow  and  last-shaped  excrescence. 

Laryngoscopic  inspection  revealed  a very  great  defect  of  the  epiglottis , of 
which  there  remained  only  the  mentioned  last-shaped  excrescence.  The  liga- 
mentum  glosso-epiglotticum  medium  is  very  much  thickened.  The  fovese  glosso- 
epiglotticae  are , on  account  of  the  deficiency  of  the  sebaceous  glands  and 
flexions  of  the  named  ligaments  very  large.  The  ligamenta  aryepiglottica  are , 


SYPHILITIC  AFFECTIONS  OF  THE  LARYNX. 


127 


like  the  false  vocal  cords  very  large  and  swollen , and  show  on  their  yellow-red 
surface  long  and  shallow  ulcers.  The  vocal  cords  are  of  the  same  color , and 
also  are  infiltrated , besides  being  grown  together  at  their  lower  point  of  attach- 
ment, so  that  in  phonation  and  deep  inspiration  no  movement  is  visible.  The 
yet  open  space  of  the  glottis  is  oval-shaped , hardly  five  to  six  millimetres  long , 
and  about  one  and  a half  or  two  millimetres  broad.  Through  the  opening  of 
the  glottis  quill-shaped  formations  are  visible , but  are  not  easily  seen. 

The  patient  complains  of  great  pain  during  deglutition  and  respira- 
tion. The  latter  is  performed  with  a certain  stridor.  The  sound  of  the 
voice  is  hoarse. 

Subcutaneous  injections  were  ordered  in  doses  of  £ gr.  of  sublimate 
pro  die.  The  treatment  was  somewhat  interrupted  on  account  of 
threatened  salivation.  After  using  2 gr.  of  this,  the  described  ulcera- 
tions of  the  pharynx  and  larynx  were  completely  gone,  but  the  mentioned 
thickening  and  infiltration  were  but  slightly  reduced.  With  the  further 
use  of  \ gr.  more  of  sublimate,  the  swelling  of  the  larynx  subsided  but 
little,  yet  the  stridor  in  breathing  was  gone.  By  urgent  request  of  the 
husband,  she  left  the  hospital  in  April,  1868.  Two  months  afterwards, 
she  gave  birth  to  a healthy  and  yet  living  child,  and  was  taken  four 
months  later  with  considerable  menorrhagia.  In  October,  of  the  same 
year,  difficulty  of  respiration  increased  so  much  that  tracheotomy  had 
to  be  performed. 

The  patient  is  now  under  my  treatment,  and  my  experiments  to  en- 
large the  stenosed  opening  by  catheterization  has  not  yet  been  crowned 
with  success. 

In  the  following  case,  deep  seated  ulcerations  in  the  larynx 
and  pharynx,  and  ulcerative  skin  affections  began  to  develop 
themselves.  The  patient  was  very  weak,  but  nevertheless 
we  used  quite  large  doses  of  sublimate  subcutaneously,  which 
quickly  effected  a complete  restoration. 


Case  38. — Charlotte  L.,  forty  years  old,  was  received  on  February 
28th,  into  the  Charite  Hospital.  The  patient  was  very  much  emaciated, 
weak  and  of  a very  cachectic  appearance.  She  was  married  fifteen  years 
ago  ; has  had  several  miscarriages,  only  one  child  being  born  alive, 
which  died  in  its  twenty-first  month,  with  convulsions.  She  farther 
says  she  has  always  been  well  up  to  four  months  ago  and  always  been 


128 


INDICATIONS  FOR  INJECTION. 


well  nourished.  Then  she  first  complained  of  pain  in  her  throat,  which 
made  deglutition  almost  impossible.  Very  shortly  afterwards,  and 
“ almost  suddenly”  spots  appeared  on  the  skin,  with  scaly  formations. 
She  used  for  her  complaints  “gargarism”  and  internal  medication, 
which  latter  seems  to  have  been  iodide  of  potassium. 

In  examination  we  found  small  superficial  ulcerations  on  the  posterior 
commisura  of  the  vagina.  On  the  head,  in  the  region  of  the  right  axilla 
and  upper  and  lower  extremities,  there  were  ulcers  which  reached  deeply 
into  the  cuticle,  and  were  covered  by  ecthymatous  and  rupia-like  crusts. 

In  the  pharynx  we  found  quite  deep  ulcerations  on  the  tonsils,  the 
arches  and  root  of  the  tongue  in  the  vicinity  of  the  ligamentum  glosso- 
epiglotticum  dextrum.  The  latter  showed  an  infiltrated  base,  and  was 
partly  covered  with  a dirty  looking  pus.  Laryngoscopic  inspection  re- 
vealed an  important  thickening  of  the  epiglottis,  whose  left  free  border 
showed  a semilunar  deficit  in  consequence  of  an  ulcer  seated  there.  The 
lig.  aryepiglottica  were  thickened.  On  the  left  thyroid  cartilage  a deep 
ulcer  was  present,  the  size  of  a bean,  and  covered  with  a grayish-white 
pus. 

On  the  left  patella  we  found  a diffused  reddened  place,  painful  to  the 
touch. 

The  treatment  of  this  intricate  case  consisted  of  baths,  to  which  bran 
was  added  ; the  subcutaneous  injections  of  sublimate  in  doses  from  Jgr. 
to  J gr.,  besides  a good  meat  diet,  and  the  liberal  use  of  wine. 

With  the  treatment  gradual  recovery  followed.  After  the  use  of  ljgr. 
the  affections  of  the  pharynx  and  larynx  disappeared,  and  also  a portion 
of  the  skin  syphiloids.  Complete  cure  of  them  was  only  effected  after 
injecting  a total  of  3 gr.  sublimate  within  four  weeks. 

In  the  next  case,  which  had  used  for  the  manifold  and 
severe  syphilitic  affection  almost  every  treatment,  a seem- 
ingly gummous  infiltration  of  the  vocal  cords,  which  were 
partly  ulcerated,  was  found.  At  the  same  time  the  subjective 
as  well  as  the  objective  signs  exhibited  a tendency  to 
perichondritis. 

Case  39. — Agnes  P.,  eighteen  years  old,  of  pale,  anaemic  appearance, 
and  flabby  muscles,  had  been,  notwithstanding  her  age,  seven  times  in 
the  Charite  for  syphilis.  The  first  time  she  suffered  with  a blennorrhaeic 


SYPHILITIC  AFFECTIONS  OF  THE  LARYNX. 


129 


and  primary  affection  ; the  sixth  time  with  broad  condylomes  and  large 
ulcers  on  the  tonsils,  together  with  a papulous  exanthem,  for  which  she 
used  a sarsaparilla  sweat  cure,  followed  with  iodide  of  potassium.  Four 
months  after  her  discharge  and  seeming  restoration,  she  again  returned 
to  the  hospital,  having  deep  ulcers  on  the  palate-roofs  and  uvula. 
Again  sarsaparilla  and  iodide  of  potassium  were  used,  and  seemed  to 
effect  a cure.  But  on  the  6th  May,  1866,  she  came  back  once  more  with 
the  following  status  prsesens : 

On  the  right  palate-roof  there  was  an  ulcer  of  the  size  of  a penny , with  sharp 
edges , deep  base,  a dirty -diphtheritic  coating , and  infiltrated  surroundings.  A 
second  ulcer  of  a lesser  size  and  same  consistency , was  situated  on  the  posterior 
wall  of  the  pharynx. 

On  the  mucous  membrane  of  the  septum  narium , there  was  a deep  seated  per- 
forating ulcer , with  swelling  in  the  vicinity . 

On  the  lower  border  of  the  nasal  opening , were  also  ulcers  of  the  same 
character  and  quill-like  elevations  of  the  size  of  a bean , red  color , and  a third 
of  an  inch  long , whose  inside  borders  were  also  ulcerated. 

The  lymphatic  glands  of  the  submaxillary  and  cervical  regions  were 
largely,  while  those  of  the  inguinal  region  were  but  slightly  swelled. 

Subcutaneous  injections  were  ordered,  and  twenty-nine  doses  ad- 
ministered,— seventeen  with  nearly  t3q-  gr.,  and  twelve  with  £ gr.  per 
dose, — so  that  altogether  4J  gr.  were  used. 

We  noticed  that  after  the  seventeenth  injection,  the  ulcerations  on  the 
posterior  wall  of  the  pharynx  were  completely  gone.  After  the  twenty- 
second  injection,  the  ulcers  on  the  nose  and  palate-roofs  were  all  per- 
fectly cicatrized.  But  the  quilt-like  formations  were  not  gone  till  after 
the  twenty-fifth  was  administered,  or  the  use  of  about  3£  gr.  Slight 
ptyalismus  occurring,  an  interruption  in  the  hypodermic  medication  of 
four  days  was  necessary  at  the  twenty-fifth  injection. 

On  the  8th  of  June,  1866,  the  patient  was  discharged,  cured. 

After  an  elapse  of  six  months,  Agnes  P.  came  again,  for  the  ninth  time, 
into  our  ward  with  a light  pigment-colored  exanthem,  and  small  isolated 
knots  of  the  size  of  a pea,  on  the  nose  and  upper  lips.  They  were  particularly 
on  the  point  of  the  nose  and  borders  of  the  nostrils.  They  were  already  deeply 
seated  in  the  cuticle , ulcerated  and  covered  with  a yellow  coating. 

Scars  on  the  septum  narium  and  contraction  produced  by  cicatrized 
ulcers,  flattened  the  nose  somewhat,  especially  at  the  point,  and  lessened 
the  openings.  Patient  said  she  had  pus-producing  pimples  on  her  nose 
three  months  ago,  which  she  opened  herself,  and  applied  to  them  11  red 


130 


INDICATIONS  FOR  INJECTION. 


precipitate”  till  salivation  commenced.  At  the  same  time  she  used 
some  sort  of  a laxative  decoction. 

We  prescribed  iodide  of  potassium  in  16  gr.  doses.  After  using  this 
remedy  four  weeks,  the  ulcers  were  healed  and  cicatrized,  and  the  pa- 
tient feeling  quite  well,  was  discharged  as  cured.  # 

After  eighteen  months  she  returned  again,  in  April,  1868 — aphonic , but 
apparently  healthy. 

Laryngoscopic  examination  revealed  that  the  vocal  cords  were  round , pale 
and  swollen  to  such  a degree  that  the  glottis  was  narrowed  in  consequence. 
They  were  deeply  ulcerated  in  the  vicinity  of  the  left  processus  vocalis. 

On  the  right  arytenoid  cartilage  we  could  see  a large  swelling  and  redness  of 
the  mucous  membrane.  On  the  lower  part  of  the  left  vocal  cord , a small  flat 
quilted  prominence  appeared,  partially  covered  with  an  ulcer.  The  right  vocal 
cord  stood  with  its  free  border  nearly  in  the  medium  line , and  remained  sta- 
tionary here  during  attempted  phonaiion , and  also  with  forced  inspiration  and 
expiration.  The  movement  of  the  right  vocal  cord  which  plainly  appeared 
with  coughing , prevented  a greater  stenosis  of  the  larynx.  Deeper  inspirations 
were  attended  with  a rough  stridor. 

The  complaints  of  the  patient  were  referred  to  deglutition  and  cough- 
ing, especially  on  the  right  side  of  the  larynx  which  seemed  painful  to 
the  touch.  Cataplasms  and  inunction  with  gray  salve  over  the  larynx, 
and  -§  gr.  doses  of  sublimate  subcutaneously  injected,  were  ordered. 
Salivation  being  feared,  we  paused  in  the  treatment  two  days,  and  after- 
wards used  only  from  -j-  gr.  to  J gr.  After  using  3 gr.  altogether,  the 
ulcers  on  the  larynx  healed,  and  the  infiltration  of  the  vocal  cords  and 
the  quilted  formations  on  the  left  chorda-vocalis  disappeared.  Subcu- 
taneous injections  were  further  used  which  effected  a perfect  cure. 

Lastly,  I wish  to  direct  the  attention  of  my  readers  to 
those  cases  of  stenosis  of  the  larynx  which  have  had  a long 
existence,  and  in  which  by  a deficient  aeration,  a blood  alter- 
ation, or  almost  blood  poisoning  is  caused.  Here  tracheotomy 
ought  to  be  resorted  to  when  impending  suffocation  occurs, 
as  the  following  case  will  show. 

Case  40. — I was  consulted  by  N.,  an  army  officer  in  1862.  He  was 
scarcely  able  to  ascend  the  stairs  on  account  of  dyspnoea.  The  diffi- 
culty in  respiration  was  so  much  that  he  could  utter  only  half  sentences, 


MACULOUS  EXANTHEM. 


131 


and  being  also  interrupted  by  a persistent  cough.  He  contracted  a 
hard  ulcer  in  1856,  and  mercurial  pills  were  prescribed,  he  faithfully 
carrying  out  the  physician’s  prescriptions.  In  the  fall  of  1860,  he 
noticed  for  the  first  time,  a hoarseness,  which,  together  with  pain  in 
deglutition,  increased  in  severity — later  dyspnoea  occurred,  and  as  time 
advanced,  it  became  greatly  augmented  ; countenance  rather  livid  ; the 
pulse  much  flexed  and  small  j and  cough  very  frequent  with  a hoarse 
dry  sound. 

Laryngoscopic  examination  revealed  a stenosis  of  the  larynx.  The 
infiltrated  vocal  cords,  covered  with  a superficial  ulceration,  were  but 
little  moved  in  inspiration — back  of  them  red  quilt-like  formations  ap- 
peared. 

Examination  of  the  chest'revealed  only  11  rales  ” and  a slight  dullness 
on  the  right  front  of  the  lung.  I thought  tracheotomy  indicated,  and 
fixed  the  next  day  to  operate.  But  when  I made  my  visit  the  following 
day,  I found  the  patient  already  dead.  Only  ten  minutes  before,  he  had 
drank  beer  brought  to  him  by  his  landlord.  Section  revealed  great 
stenosis  of  the  larynx.  The  sides  of  the  laryngeal  cavity,  behind  the 
vocal  cords,  were  swollen  in  such  a manner  that  only  a fissure  re- 
mained, and  this  was  still  more  narrowed  by  the  thickened  mucous 
membranes  of  the  posterior  wall  of  the  larynx.  The  vocal  cords  were 
infiltrated  and  showed  superficial  loss  of  substance. 

Similar  cases  in  suffocation  occurring  after  a longer  exist- 
ing stenosis  of  the  larynx  are  reported  by  Green  (American 
Jour.  Med.  Sciences,  1851) ; by  Pravaz,  (Lebert  Traits 
d’anatom,  tom.  I.) ; Tourdes,  (Gaz.  des  Hosp.,  1853,  No. 
12) ; Senn,  (Jour,  des  Science  Med.,  tom.  V.,  p.  230),  &c. 

VI.  SYPHILITIC  SKIN  AFFECTIONS. 

MACULOUS  EXANTHEM. 

Before  commencing  upon  the  therapeutics  of  the  diseases 
of  the  skin , occurring  in  the  first  period  of  syphilis — that 
extended  territorium  in  which  the  dyscrasia  of  blood  estab- 
lishes disturbances  of  nutrition  from  a simple  hypeaermia, 


132 


SYPHILITIC  SKIN  AFFECTIONS. 


as  patches  and  erythema,  up  to  the  deeper  gummous  ulcera- 
tions— I ^hall,  irrespective  of  those  cases  in  which  the  ex- 
anthemata are  only  companions  of  other  syphilitic  affections, 
and  therefore  to  be  classed  under  general  therapeutics,  place 
the  following  principles  the  first  in  order. 

If  the  exanthemata  show  only  slight  redness,  if  they  do  not 
possess  a specific  character,  if  there  are  wanting  these  singu- 
lar polymorphous  skin  efflorescences  only  seen  in  syphilis, 
and  especially  if  they  have  no  explainable  connection  of  the 
lower  formations  to  the  higher  ones,  I always  treat  such 
cases,  at  first,  in  the  expectant  method . 

But  if  this  is  impracticable  and  energetic  treatment  seems 
to  be  needed,  then  I inject,  by  way  of  trial,  small  doses  of 
sublimate.  If  they  are  well  borne  and  show  good  result,  I 
even  use  for  the  entire  curing  of  the  exanthem  further  in- 
jections till  I have  used  at  least  2J  gr.  of  the  sublimate. 
But  if  no  results  are  apparent  then  I lay  aside  the  subcuta- 
neous medication. 

The  diagnosis  of  a maculous  syphiloid  in  its  earliest  com- 
mencement, cannot  be  devoid  of  more  or  less  difficulty,  par- 
ticularly if  the  characteristic  coloring  is  absent,  and  the 
hypersemic  redness  of  the  patches  in  contrast  to  the  paler 
hue  does  not  appear.  Even  exposure  of  the  body  and  the 
coldness  thereby  produced,  will  often  fail  to  bring  out  this 
contrast  in  color. 

In  such  cases,  of  diagnostic  value  are  the  complications  with 
other  syphilitic  symptoms , which  occur  at  this  period  of  syph- 
ilis— as  the  connection  of  the  mucosa  of  the  pharynx,  the 
defluvium  capillorum,  and  the  swelling  of  the  lymphatic 
glands.  But  the  first  two  symptoms  are  very  inconstant, 
and  the  third  symptom  is  difficult  to  estimate  on  account 


MACULOUS  EXANTHEM. 


133 


of  not  knowing  the  normal  size  and  consistence  of  the 
glands,  and  hence  the  three  are  often  almost  valueless. 

A non-syphilitic  roseola  is  a rarity . Roseola  patches  oc- 
curring with  exanthematous  diseases,  as  morbilli,  scarlatina, 
typhus,  have  all  characteristic  differences,  and  besides  are 
accompanied  with  concomitant,  febrile,  catarrhal  or  angi- 
nous  appearances,  which  are  in  strong  contrast  with  devel- 
oping syphiloids.  Roseola  balsamica , which  is  formed  some- 
what similarly  to  the  syphilitic,  is  generally  combined  with 
hyperesthesia  of  the  nerves  of  the  skin,  and  it  disappears 
as  quietly  and  suddenly  as  it  appears.  Substantive  roseola 
is  a morbillous  or  scarlatinous  process  which  almost  in  its  in- 
cipiency  begins  to  disappear  and  cannot  be  confounded  with 
roseola  syphilitica .* 

I have  very  often  noticed  "that  on  the  inside  of  the  upper 
thigh,  the  first  signs  of  syphilitic  eruption  appeared,  and 
here  showed  the  characteristic  pale,  copper-red  color,  pro- 
duced by  the  change  in  the  haematine  of  the  blood,  but 
without  developing  itself  afterwards  to  a clear  roseola 
elevata. 

The  therapeutic  effect  of  the  subcutaneously  injected  sub- 
limate on  the  maculous  syphiloid  is  generally  a very  satis- 
factory and  quick  one,  and  compares  very  favorably  with 
the  success  of  other  standard  treatments.  According  to 
Zeissl  (p.  103),  “ erythematous  syphiloid  disappears  with  a 
mercurial  treatment  in  a fortnight.' 9 Engelsted*  puts  the 
average  time  for  treating  the  same  complaint  at  four  and  a 
half  .weeks  ; the  shortest  period  three  weeks,  and  the  longest 
six  w’eeks.  The  chief  remedies  for  these  skin  affections  are, 
according  to  Engelsted,  calomel  and  sublimate,  either  alone, 

* Constitutional  Syphilis.  Translated  by  C.  Uterhart,  Wurzburg, 

1861,  p.  10. 

12 


134 


SYPHILITIC  SKIN  AFFECTIONS. 


or  combined  with  iodide  of  potassium  and  decoctum  sarsa- 
parilla. 

In  the  cases  treated  by  me  the  amount,  for  complete 
eradication,  was  from  If  gr.  to  If  gr.  of  sublimate. 

That  there  are  exceptional  cases  where  larger  doses , and 
a longer  time , are  necessary,  I will  not  dispute.  But  never 
was  it  necessary  to  use  large  doses  for  such  a length  of  time 
as  I have  mentioned,  with  the  use  of  the  decoctum  sarsa- 
parilla compositum,  or  as  Engelsted  notes  for  several  of  his 
patients. 

Those  patients  which  came  under  my  care  in  a relapsing 
stage  of  syphilis,  already  having  erythema  annulatum , re- 
quired larger  doses.  These  cases  had  generally  very  bad 
result  on  account  of  the  syphilitic  sequela  always  coming  at 
a certain  period.  In  some  cases  the  patches  became  redder 
instead  of  paler  after  the  first  injections,  and  even  more  ele- 
vated, but  by  steadily  continuing  the  medication  the  eruption 
disappears  in  due  time.  This  is  the  case  with  all  anti- 
syphilitic treatments,  either  botanic  or  mercurial.  Ac- 
cording to  Zeissl,  “ all  anti-syphilitic  treatments  caused  an 
increase  in  the  development  of  the  elementary  formation  of 
syphilitic  efflorescence.” 

Lastly,  I wish  to  direct  the  attention  of  the  reader  to  a 
new  species  of  non- syphilitic  maculous  exanthema , which, 
according  to  my  knowledge,  has  not  yet  been  described,  and 
to  which  I have  been  partly  directed  by  Staff  Surgeon  Dr. 
Lommer.  The  same  manifests  itself  by  a quantity  of  large 
“ pea-sized”  spots,  of  a peculiar  pale  blue  color,  which,  for 
this  reason,  we  have  named  exanthema  coeruleum . This 
color  is  very  dissimilar  to  the  “ mulberry  rash  ” of  the  large 
flecked  syphiloid,  unlike  the  ordinary  copper-red  hue,  and 
very  different  from  the  gray  lead  color  of  pigment  spots. 


PAPULOUS  EXANTHEMA. 


135 


Although  we  noticed  this  bluish  maculous  exanthem  at 
first  only  with  syphilitics,  later  observations  revealed  that 
quite  as  often  it  occurred  with  the  non-infected,  and  that  it 
appears  without  a syphilitic  blood-dyscrasia  pre-existing. 

As  to  the  genesis  of  this  singular  exanthem,  which  I have 
mostly  observed  on  the  sides  of  the  chest,  I can  give  only 
this  explanation,  that  I think  it  is  produced  by  a venous 
conglomeration  and  the  blue  pale  color  is  caused  by  an  over- 
lying  adipose  covering. 

PAPULOUS  EXANTHEMA. 

Diagnosis  of  the  papulous  syphiloid  is,  only  in  a few  cases, 
difficult.  As  with  the  maculous  syphiloid,  it  is  difficult  only 
in  the  incipiency  of  its  formation,  namely , when  the  dirty 
brown  red  color , caused  by  the  lenticular  character  of  the 
syphilis , has  not  yet  appeared . And  further , efflorescences 
are  present  only  in  a few  species . 

In  the  obscure  cases  all  the  other  data  and  symptoms 
must  be  considered,  in  order  to  make  out  the  diagnosis ; as 
the  concomitant  symptoms,  the  date  of  the  infection  and 
locality  of  the  papules , &c.  It  is  of  importance  to  find  out 
whether  they  are  seated  in  their  favorite  places,  as  in  the 
bend  of  the  extremities,  especially  the  plica  cubitalis,  fossa 
poplitea,  and  near  the  hair  on  the  forehead,  neck,  chin,  &c. 

The  miliary  species  of  this  syphiloid  is  easily  diagnosed. 
They  show  their  syphilitic  character  early,  by  a regressive 
and  progressive  metamorphosis.  Sometimes,  however,  the 
diagnosis  is  embarrassed,  inasmuch  as  often  with  the  rapidly 
appearing  eruption  of  the  small  papules,  febrile  and  nervous 
appearances  occur,  which  are  generally  absent  in  syphilitic 
exanthemata, — the  febrile  first  showing  itself  with  a higher 


136 


SYPHILITIC  SKIN  AFFECTIONS. 


temperature  and  accelerated  pulse,  while  the  nervous  is 
attended  with  more  or  less  itching  of  the  skin  in  the  affected 
regions.  In  consequence  of  this  pruritus , the  small  papules 
are  very  often  scratched  open  by  the  patient,  so  that  the 
efflorescences  are  subsequently  covered  with  bluish-black 
crusts. 

The  lenticular  species  progresses  more  slowly.  Only  after 
a lapse  of  time,  are  a part  of  the  efflorescences  flattened, 
desquamated  and  covered  with  their  scabs.  The  more  coni- 
cal and  pointed  papules  take  on  the  vesiculous  and  pustulous 
formations. 

More  difficult  is  the  diagnosis  in  those  cases  in  which  the 
papulous  exanthema  occur,  and  which  is  the  only  symptom 
of  relapsing  syphilis.  Here  is  a tendency  for  the  efflores- 
cences to  group  themselves  in  certain  configurations,  as  in 
an  irregular,  coil-like  formation,  or  in  a crescentic  shape. 
This  occurring,  forms  a good  basis  for  diagnosis. 

With  few  exceptions  have  I noticed  in  recent  cases  of 
papulous  syphiloid,  fine,  circular  formations  only  four  or 
five  lines  in  diameter,  which  appear  on  the  face  and  neck. 
They  consist  of  small  narrow  papules  of  the  size  of  a pin’s 
head,  covering  themselves  quickly  with  pale  red  scales  of 
nearly  the  same  dimensions.  But  care  must  be  taken  not 
to  confound  such  formations  with  a similar  species  of  the 
herpes  circinatus . 

Concerning  the  therapeutics , subcutaneously , of  both  de- 
scribed species,  I commence  and  conduct  the  treatment*  in 
accordance  with  the  above-described  principle.  When  the 
diagnosis  is  so  uncertain  that  even  an  experienced  syphilo- 
grapher  would  be  in  doubt,  I inject  then  only  small  quantities 
of  sublimate  by  way  of  trial. 

But  I use  the  injection  continuously,  even  after  the  pap- 


PAPULOUS  EXANTHEMA. 


137 


ules  show  a tendency  to  desquamate  and  when  they  are 
covered  with  fine  lamellae,  peeled  off  from  the  epithelial 
scales,  also  even  when  some  small  papules  increase  in 
volume. 

It  requires  only  a few  days  longer,  and  the  treatment 
with  the  sublimate  will  show  its  beneficial  result  on  the 
papulous  efflorescences,  they  getting  paler  very  quickly, 
being  soon  after  perfectly  healed. 

The  healing  of  the  papulous  syphiloids  require  on  an  ave- 
rage from  J gr.  to  \ gr.  more  than  the  maculous . But  in 
some  patients  even  greater  doses  are  necessary. 

The  resistance  to  treatment  of  the  named  exanthema,  in 
certain  cases,  is  known  to  all  syphilographs.  In  former 
years,  when  I relied  more  on  the  sarsaparilla  sweat  cure,  I 
met  cases  where,  after  months  even,  the  papules  were  in 
full  bloom,  and  where  a ‘repetition  of  the  treatment,  in  com- 
bination with  iodide  of  potassium,  effected  no  curative  result. 
Similar  experience  I have  sometimes  had  with  the  inunction 
cure,  which  was  energetically  applied,  but  without  result. 
And,  indeed,  it  is  surprising  to  witness  the  relatively  quick 
healing  of  this  obstinate  exanthema  by  the  use  of  subcuta- 
neous injections ; and  we  need  not  he  satisfied  with  \ gr. 
doses  pro  die , but  may  even  risk  larger  quantities , as  for 
instance , J gr.  or  J gr.  pro  die. 

In  the  following  cases  I shall  show  that  while  in  some 
patients  neither  a mercurial,  nor  the  sarsaparilla  sweat  cure 
treatment,  energetically  used,  was  sufficient  to  destroy  the 
papulous  exanthem,  and  that  finally  subcutaneous  injection 
produced  complete  restoration. 

Case  41. — Anna  B.,  eighteen  years  old,  was  received  August  22d,  1866. 
Examination  revealed  a soft  ulcer  in  the  fossa  naviculare  vaginoe,  va- 
ginal discharge,  urethritis  and  erosions  on  the  clitoris.  Although  the 

12* 


138 


SYPHILITIC  SKIN  AFFECTIONS. 


erosions  had  a suspicious  11  look/’  yet  no  sure  grounds  for  diagnosis  of 
syphilis  could  be  detected,  so  I tried  at  first  a local  treatment  only. 
After  four  weeks  syphilis  manifested  itself  in  the  form  of  a maculous 
exanthema , accompanied  with  pale  red  papules  of  the  size  of  a pea  situated 
on  the  forehead , hack  and.  forearm.  A large  efflorescence  had  developed  itself 
on  the  upper  lip  cmd  between  the  left  nostril  and  angle  of  the  mouth.  On  the 
latter  a condylomatous  erosion  was  situated.  The  lymphatic  glands  in 
the  left  inguinal  region  were  swollen  and  painful  to  the  touch.  We 
prescribed  the  sarsaparilla  sweat  cure.  After  using  it  for  seven  weeks 
a number  of  desquamating  papules  still  remained.  On  this  account  we 
used  the  subcutaneous  medication,  and  after  a lapse  of  eight  days,  six 
injections  of  \ gr.  each,  of  sublimate,  produced  perfect  recovery. 

Case  42. — Louisa  M.,  twenty-one  years  old,  of  healthy  constitution, 
but  pale  complexion,  had  already,  June,  1866,  on  account  of  papulous 
exanthema,  undergone  a sarsaparilla  sweat  cure  of  six  weeks  duration. 
Three  months  afterwards  the  same  appeared  again,  and  similar  treat- 
ment was  instituted. 

Returning  for  the  third  time,  April  20th,  1867,  into  the  Charite,  the 
peculiar  condition  of  the  gums  and  breath  aroused  my  suspicion  that 
she  had  taken  mercury.  By  inquiry  she  owned  that  she  had  under- 
gone Dzondi’s  cure  and  had  taken  about  150  pills. 

Status  prsesens : Small  erosions  on  the  vaginal  opening ; the  vaginal 
portion  of  the  uterus  much  swollen,  especially  the  posterior  part  of  the 
os , which  was  hard  and  superficially  eroded.  Tonsils  largely  swelled 
and  much  reddened.  In  the  neighborhood  of  the  glutei  there  were 
crusts  resembling  impetigo.  On  the  body  there  were  numerous  papules , 
particularly  on  the  back , posterior  surface  of  the  arms)  forehead  and  neck . 
Here  they  were  aggregated  into  the  form  of  half  circles , one  and  a half  inches 
in  diameter.  The  single  efflorescences  had  the  circumference  of  a lentil  up  to 
the  size  of  a pea)  being  of  a dirty  brown  hue  and  destitute  of  scales.  The 
papules  were  rather  indurated.  On  the  head  there  was  occasionally  a small 
crust.  Of  the  lymphatic  glands,  the  cervical  and  right  axillary  and 
cubital  were  very  hard  and  greatly  swollen. 

To  prevent  further  salivation  we  gave  the  patient  chlorate  of  potassa 
as  a gargarism  and  internally.  After  all  symptoms  of  ptyalism  had 
disappeared  we  began  the  use  of  hypodermic  injections.  After  the  sixth 
injection  of  ^ gr.  of  sublimate  each,  the  vaginal  erosions  were  already 
gone.  Here  we  had  to  suspend  the  subcutaneous  treatment  on  account 
of  symptoms  of  ptyalism,  but  resumed  it  after  the  lapse  of  four  days, 


PAPULOUS  EXANTHEMA. 


139 


giving  -J-  gr.  pro  die.  The  papules  became  more  flat  and  some  began  to 
desquamate.  After  the  use  hypodermically  of  1 J gr.  more)  the  healing  of  the 
papules  was  complete , and  only  small  spots  of  a pale  brown-red  color  remained. 
The  disappearance  of  the  glandular  swelling  had  not  taken  place  in  the 
same  proportion. 


Case  43. — Augusta  Schn.,  thirty-eight  years  old,  received  into  the 
Charite  June  27th,  1866. 

Patient  says  her  present  disease  was  discovered  only  some  six  weeks 
ago,  for  which  she  had  taken  twelve  sublimate  pills  and  two  bottles  of 
medicine,  the  ingredients  of  which  she  was  ignorant. 

Status  prsesens : On  the  right  labium  maj.  there  was  an  ulcer  of  the 
size  of  a Mexican  dollar,  with  an  indurated  base,  covered  with  a fatty 
pus-like  secretion.  On  the  left  labium  min.  there  was  an  ulceration 
of  less  extension  but  of  the  same  character.  Pale  brown  scabs  were 
visible  on  the  right  nostril.  The  skin  of  the  whole  body,  especially  on 
the  back,  chest  and  abdomen,  was  thickly  covered  with  a maculous  exanthem , 
irregularly  scattered  about.  Some  were  topped  with  small  scales , others  were 
metamorphosed  ' into  diminutive  papules.  On  both  tonsils  and  on  the  seba- 
ceous glands  at  the  root  of  the  tongue,  gray-white  condylomatous  ero- 
sions could  be  seen.  The  lymphatic  glands  were  much  swollen  in  the 
inguinal  region,  but  only  moderately  in  the  submaxillary. 

The  patient  was  treated  at  her  own  request  with  the  u sarsaparilla 
sweat  cure.”  During  the  same,  the  maculae  became  more  reddened, 
although  some  of  the  spots  got  paler  and  still  others  lead-colored.  To 
our  surprise , a lenticular  papulous  exanthem  developed  itself  on  the  back  and 
upper  arm. 

After  four  weeks  of  the  above  treatment  we  suspended  the  same  on 
account  of  increasing  weakness  and  a tendency  to  vomiting.  After  a 
pause  of  eight  days  we  observed  an  important  increase  of  the  papulous  syphi- 
loid; besides,  we  detected  that  the  ulcerations  at  the  labia  majora  were 
not  much  softer,  and  therefore  we  determined  to  try  the  hypodermic 
medication. 

On  account  of  the  extreme  debility  of  the  patient,  we  injected  only 

gr.  doses  of  sublimate,  and  soon  increased  to  J gr.,  and  then  £ gr. 
After  using  but  1 gr.  the  ulcers  were  cicatrized  over  and  their  hardness 
very  much  diminished. 

The  papules , which  were  already  considerably  reduced  when  | gr.  had  been 
usedj  were  entirely  gone  when  1 gr.  had  been  administered , without  leaving  the 


140 


SYPHILITIC  SKIN  AFFECTIONS. 


usual  pigment  colored  spots.  But  to  eradicate  the  remainder  of  the  indu- 
ration, a further  quantity,  to  the  amount  of  grs.  altogether,  was 
necessary. 

• SQUAMOUS  EXANTHEM. 

This  squamous  syphiloid  is  mostly  developed  by  cellular 
proliferation  from  the  papules,  and  on  this  account  we  find, 
besides  papules  covered  with  scales,  many  which  have  not 
yet  taken  on  this  metamorphosis,  and  hence  diagnosis  is 
more  easily  made. 

Besides  this  characteristic  polymorphic  of  the  efflores- 
cences, this  syphiloid  is  always  preceded  by,  or  simulta- 
neously attended  with,  syphilitic  processes  in  other  organs. 

The  epidermic  scabs  in  squamous  syphiloid  are  disinte- 
grated generally  from  the  thicker  scabs,  as  we  see  them 
sometimes  in  genuine  psoriasis,  by  being  very  thin,  yellow, 
red  or  shiny  white,  and  appearing  as  if  varnished.  Their 
seat  is  mostly  in  the  centre  of  the  papules,  and  seldom  in 
the  periphery,  having  a wreath-like  formation. 

In  some  cases  the  character  of  the  squamous  syphiloid  is 
somewhat  clouded — as,  for  instance,  when  the  epidermic 
scabs  are  not  seated  on  the  papule,  but  directly  on  the  adja- 
cent reddened  cuticle,  as  it  occurs  in  relapses  after  our  sub- 
cutaneous treatment.  The  scabs  then  are  thicker  and 
cement-like,  resembling  psoriasis  vulgaris  in  appearance. 
The  difficulty  in  diagnosis,  under  the  circumstances,  is 
much  lessened,  when  the  locality  and  configuration  of  the 
papules  are  considered.  The  size  of  papules  varies  between 
the  bulk  of  a lentil  and  size  of  a pea,  seldom  getting 
larger.  But,  by  confluence  of  the  small  efflorescences, 
greater  formations  may  be  developed. 

The  scales  of  the  genuine  psoriasis,  in  opposition  to  the 


SQUAMOUS  EXANTHEM. 


141 


syphiloid,  very  seldom  remain  in  their  primary  smallness 
(psoriasis  punctata),  but  gradually  acquire  the  size  of  a penny 
(psoriasis  numularis),  soon  assuming,  by  a central  drying 
process  of  the  scabs,  a circle-like  formation  (psoriasis  annu- 
lata).  As  characteristic  of  the  squamous  syphiloid,  as  well 
as  of  all  syphiloids,  is  polymorphic — i.  e .,  a simultaneous 
appearance  of  more  than  one  species  of  efflorescences,  while 
the  genuine  psoriasis  has  a tendency  to  variations  in  the 
formations  of  the  same  efflorescence. 

Among  the  syphiloids,  the  squamous  shows  the  greatest 
inclination  for  those  regions  for  which  the  already  named 
papulous  evince  a predilection.  The  skin  of  the  head  is  one 
of  these  regions,  and  this  valuable  diagnostic  singularit 
predominates  here,  viz. : that  generally  the  scabs  change 
themselves  very  easily  into  crusts,  situated  on  ulcerated 
bases ; but  with  psoriasis  on  the  parts  of  the  head  covere 
with  hair,  crusts  do  not  form,  but  commonly  only  thin  dirty 
white  gray  scabs,  and  in  such  an  abundance  that  they 
strikingly  remind  us  of  the  picture  of  the  “ Tinea  furfura- 
cea”  of  the  older  authors.* 

I used  likewise  for  the  squamous  -syphiloid  subcutaneous 
injections,  without  any  local  treatment,  as  in  the  two  already 
described  formations,  with  a generally  curative  result.  In 
only  exceptional  cases,  when  the  exanthem  was  situated  on 
the  face,  neck  or  hands,  did  I use  inunction,  and  then  with 
compounds  of  oleum  cadini  with  hydrargyrum  chloratum 
mite,  having  a good  result. 

As  is  well  known,  the  squamous  syphiloid,  and  especially 

• 

* Tinea  furfuracea,  or  Weichselzopf,  is  a disease  met  very  frequently 
in  Poland,  being  caused  by  uncleanliness,  and  destroying  the  hair  en- 
tirely, leaving  nothing  but  a mass  of  scab.  In  very  rare  cases  the  scabs 
thicken,  making  a crust  two  inches  thick. — Translator’s  Rem. 


142 


SYPHILITIC  SKIN  AFFECTIONS. 


that  which  is  called  psoriasis  palmaris  and  plantaris,  is  the 
most  obstinate,  always  resisting  the  older  anti-syphilitic 
therapeutics ; but  I can  assure  you  that  with  the  subcuta- 
neous injection,  all  formations  improved  gradually,  healing 
being  the  result  in  almost  every  case. 

I have  to  add  here  that  I do  not,  like  many  syphilographs, 
hold  the  opinion  that  psoriasis  palmaris  and  plantaris  indi- 
cate a quick  removal,  and  therefore  immediate  and  energetic 
treatment.  On  the  contrary,  I have  learned  by  my  obser- 
vations, that  both  of  these  affections  may  exist  a number  of 
years,  without  evincing  that  the  syphiloid  is  nourished  by 
any  infection  in  the  blood. 

I allowT  myself  to  give  the  following  two  interesting  cases, 
illustrative  of  my  above  remarks  : 


Case  44. — Carl  S.,  tailor,  twenty-six  years  old;  received  into  the 
Charite  December  7,  1867.  The  recollection  of  this  unreliable  patient 
failed  to  give  us  any  sure  data.  He  was  of  healthy  constitution,  but  of 
pale  appearance.  Status  prsesens  : On  the  skin  of  the  penis  and  scrotum 
and  around  the  anus  are  broad  condylomes  ; on  the  prepuce  an  inflam- 
matory phymosis  is  discernible.  The  whole  surface  of  the  body  is 
covered  with  an  exanthem,  which  has  a maculous,  papulous  and  squa- 
mous character . The  exanthem  has  reached  such  an  extension  that  only 
on  the  thorax  are  there  small  spaces  free  from  it,  the  remainder  of  the 
skin  having  a spotted  appearance.  The  face  is  especially  noticeable, 
being  thickly  flecked  with  papulous  efflorescences.  In  both  ears  otor- 
rhoea  is  present.  On  the  left  nostril  are  several  large,  moist  papulous 
efflorescences,  almost  like  broad  condylomes  ; on  the  mucous  membrane 
of  the  nose,  erosions  ; on  the  left  angle  of  the  mouth,  small  ulcerations  ; 
and  on  the  anterior  roof  of  the  palate,  condylomatous  ulcerations.  On 
the  inside  of  the  hand  the  syphiloid  has  the  appearance  of  psoriasis. 
There  is  defluvium  capillorum  jto  a slight  degree,  and  the  right  inguinal 
glands  are  swollen  to  the  size  of  a hazelnut,  while  the  left  are  as  large 
as  a walnut  and  very  hard.  The  occipital,  cervical  and  axillary  glands 
are  swollen,  but  the  cubital  are  intact. 

We  ordered  the  injection  treatment,  which,  after  being  used  twenty 


SQUAMOUS  EXANTHEM. 


143 


days,  resulted  in  a cure.  We  began  with  £ gr.  doses.  After  using  If 
gr. — i.  e.,  after  the  sixth  injection — the  condylomes  had  only  slight  ele- 
vations remaining,  a portion  of  the  papules  were  healed  and  the  scabs 
on  the  face  had  disappeared,  with-  the  exception  of  the  few  on  the 
nostril.  The  psoriasis  of  both  hands  was  already  gone  at  the  fifth  in- 
jection. After  the  twelfth  injection — i.  e .,  when  2f  grs.  of  sublimate 
had  been  used — the  broad  condylomes  were  entirely  gone  ; and  so  also 
the  exanthem,  there  only  remaining  a few  pigment  spots  of  a brown 
coffee  color  on  the  nose  and  chin.  After  using  -J  gr.  more,  all  the  other 
affections  were  destroyed.  So  that  with  fourteen  injections,  making  a 
total  of  2f  grs.  of  sublimate,  the  patient  was  discharged  completely 
cured.  TJie  patient  for  only  a few  days  had  a slight  stomatitis. 

Case  45. — Albert  G.,  joiner  by  trade,  thirty  years  old,  was  received 
February  22,  1866,  into  the  Charite.  The  patient  says  that  about  six 
months  ago  he  indulged  for  the  last  time  in  coitus,  but  some  time  subse- 
quently he  noticed  his  present  disease. 

Status  prsesens : A partially  eroded  and  partially  ulcerated  sclerosis  on 
the  prepuce,  nearly  transformed  into  a cartilaginous  ring,  producing 
such  pressure  on  the  glands  that  several  ulcers  are  the  result.  Around 
the  anus  and  on  the  shin  of  the  thorax  and  bach  there  is  an  exanthem  of  a 
papulous-squamous  character.  There  is  light  defluvium,  and  from  both 
ears  a serous,  pus-like  secretion  flows,  and,  according  to  the  patient, 
only  during  the  last  two  days.  He  complains  of  a deafness,  particu- 
larly in  the  right  ear,  which  had  existed  for  the  last  two  weeks.  The 
lymphatic  glands  in  the  inguinal  and  cubital  regions  are  as  large  as  a 
walnut,  while  the  cervical  glands  are  less  in  size. 

The  patient  first  took  a sarsaparilla  sweat-cure.  After  using  it  six 
weeks,  and  there  being  no  material  benefit  following  it,  subcutaneous 
injections  were  given,  in  the  strength  of  f gr.  per  dose.  The  total  of 
2J  grs.  of  sublimate,  given  in  seventeen  injections,  was  sufficient  to  es- 
tablish a cure  in  three  weeks.  After  the  tenth  injection  (If  gr.  subli- 
mate being  used),  the  sclerosis  of  the  prepuce  subsided,  the  phymosis 
having  been  previously  operated  upon.  The  deafness  was  also  much 
improved.  After  the  eleventh  injection  (If  gr.  sublimate  having  been 
used),  the  papulous  efflorescences  and  a part  of  the  squamous  were 
gone  ; and  after  the  last  injection,  they  altogether  vanished. 


144 


SYPHILITIC  SKIN  AFFECTIONS. 


CONDYLOMATOUS  EXANTHEMA. 

Closely  connected  with  the  papulous  exanthem  is  a syphi- 
loid, which  in  the  first  phase  of  its  existence,  stands  on  the 
same  histological  basis  as  the  lenticular  species,  but  very 
soon  it  oversteps  the  boundary  and  develops  so  rapidly  that 
penny  and  dollar  sized  efflorescences  are  formed,  which  later 
resemble  the  broad  condylomes  on  the  genitals,  and  remind 
one  of  their  typical  elementary  formation,  and  therefore  we 
name  it  condylomatous  exanthema . Having  reached  this 
state  of  development,  the  efflorescences  remain,  only  excep- 
tionally, in  an  aggregated  state,  but  they  undergo  a further 
metamorphosis.  Like  all  the  products  originated  by  syphilis, 
they  break  down  either  spontaneously  on  their  surface  into 
fatty,  dirty,  mush-like  detritus,  or  change  into  dirty,  brown 
crusts,  especially  when  the  outward  circumstances  hasten 
the  molecular  destruction. 

I have  observed  in  two  individuals  a further  development 
of  syphilis  in  which  ulcerations  of  the  size  of  a walnut  were 
formed,  they  being  partly  destroyed  in  the  above  described 
manner  on  their  surface ; and  partly  having  a glandular  ap- 
pearance, resembling,  in  consequence,  monstrous  w^arts. 

Among  the  records  of  five  hundred  patients  published  in 
my  former  work,  I find  that  this  condylomatous  exanthem 
occurred  with  eleven  patients. 

6 times  with 356  women 

5 “ 144  u 

Concerning  the  statistics  of  accompanying  symptoms  in 
women , it  was  present  with 

Affection  on  the  genitals  : 

^Condylomata  lata,  ....  5 times  = 1.4  per  cent. 

Erosions,  . . . . . 1 u = 0.69  “ 


CONDYLOMATOUS  EXANTHEMA. 


145 


Affection  of  the  skin : 

Exanth.  maculosum, 

“ maculo-papulosum,  . 

“ squamosum, 

11  maculo-pap-squam,  . 

u papulo-squamosum,  . 

11  papulo-impetiginosum, 


1 time  = 0.69  per  cent. 
^ cc  cc  cc 

X cc  cc  a 

l u n a 

l u cc  cc 

l cc  cc  cc 


Affection  of  the  fauces  : 

In  all  cases  of  condylomatous  granulations,  and  mostly  on  the 
tonsils. 


WITH  MEN. 


Affection  on  genitals : 

Ulcus  durum,  ..... 

2 times 

==  1.38 

per  cent, 

Erosis  dura, 

1 “ 

0.69 

cc 

Extensive  condylomes, 

2 “ 

1.38 

cc 

Affections  on  the  skin  : 

Exanth.  maculosum, 

1 time 

c=9  0.69 

cc 

u 11  with  purpura, 

1 “ 

cc 

u 

11  papulo-squamoso-lupos.  . 

1 “ 

cc 

cc 

11  impetiginosum,  . 

1 “ 

cc 

cc 

11  papulo-pustulosum,  . 

1 « 

cc 

cc 

Affection  of  the  fauces  : 

Broad  condylomes  with  tonsils, 

2 times 

= 1.38 

cc 

The  quantity  of  sublimate  necessary  for  a cure  was,  on  an 
average,  2J  grains. 

To  illustrate  the  different  formations  of  the  exanthemata 
and  the  efficacy  of  my  treatment,  the  following  cases  are 
selected,  of  which  the  second  is  interesting,  on  account  of  the 
already  mentioned  large  tumors  of  a condylomatous  char- 
acter, which  were  formed  in  such  magnitude  as  I have  never 
elsewhere  seen  nor  found  mentioned  in  medical  literature. 
At  the  same  time  the  case  is  an  evidence  of  the  assertion 
made  that  even  with  inebriates  subcutaneous  medication  is 
not  contra-indicated. 


13 


146 


SYPHILITIC  SKIN  AFFECTIONS. 


Case  46. — John  R.,  coachman,  thirty-eight  years  old,  received  into 
the  Charite  Hospital  July  9,  1866.  The  patient  had  contracted  a hard 
ulcer  on  the  prepuce  in  1865,  and  was  treated  for  the  same  with  the 
sarsaparilla  sweat  cure,  in  our  hospital.  The  result  was  not  very  lasting, 
for  a short  time  afterwards,  he  had  a relapse  of  the  ulcer. 

He  returned  into  our  hospital,  July  9,  1866,  with  the  following  status 
prxsens : On  the  folds  of  the  thighs  are  quilt-like  elevations  £ of  a line 
in  height  and  same  in  width,  in  the  shape  of  a horseshoe,  consisting  of 
confluent  condylomatous  granulations,  covered  on  the  surface  with  a 
fatty  mush-like  secretion. 

On  the  dorsal  surface  of  the  penis  were  several  serpiginous  ulcerations, 
which  are  partly  surrounded  by  broad  superficial  eroded  condylomes. 
On  the  scrotum  condylomata  lata  has  a more  mixed  character  shooting 
out  in  pointed  ulcerations,  small  bundles  from  the  broad  surface.  On 
the  forehead  we  perceive  a number  of  granulated  places  of  the  size  of  a penny, 
having  the  above  described  character  of  the  condylomatous  exanthem.  In  the 
middle  of  the  forehead  they  have  more  of  a warty  appearance.  On  the  border 
of  the  hair  they  are  already  ulcer atively  destroyed.  On  the  thorax,  abdomen 
and  lower  extremities  purpura-patches  of  the  size  of  a pin’s  head,  are 
scattered,  and  in  the  umbilicus  is  a moist  granulated  condylome.  The 
inguinal  glands  are  the  only  lymphatics  swollen,  being  of  the  size  of  a 
walnut. 

After  ten  injections  (ljgr.  subl.  being  used)  the  condylomatous  ex- 
anthema began  to  heal.  After  sixteen  injections,  the  purpura  patches 
disappeared,  also  the  lata  on  the  genitals,  bend  of  the  thighs  and  umbi- 
licus. The  other  symptoms  disappeared  also  after  the  twenty-fourth 
injection,  3 gr.  of  sublimate  altogether  having  been  used. 

Case  4 1. — August.  B.,  peddler,  fifty-eight  years  old,  received  into  the 
Charite  January  2,  1869.  Patient  says  that  seven  months  before  his 
entering  the  hospital,  he  was  for  the  first  time  syphilitically  infected. 
At  this  time  he  noticed,  two  weeks  after  his  last  coitus,  a superficial 
peeling  off  of  the  glans  which  quickly  healed  with  the  use  of  chamo- 
mile fomentations,  without  having  to  consult  a physician.  He  noticed 
seven  weeks  afterward  scabs  and  crusts  on  his  scalp,  but  he  used  no 
remedy  for  them.  Status  prxsens : Patient  has  flabby  muscles  and 
an  oedematous  appearance,  making  the  impression  of  a u hard  drinker,” 
which  is  confirmed  by  his  own  statement,  he  twice  having  had  delirium 
tremens. 

The  whole  back  of  his  head , the  skin  of  the  body  and  lower  extremities 


ULCEROUS  EXANTHEM. 


147 


partly ; and  the  chin  and  nose  are  covered  with  indented  tumors  of  the  hulk  of  half 
a walnut.  On  the  back  of  the  head  they  are  so  closely  together  that  they  form 
a confluent  tumor  of  the  size  of  a small  fist.  The  smaller  tumors  are  of  a pale 
red  color , covered  with  thin  impetiginoid  crusts.  The  somewhat  larger  tumors 
have  an  intact  surface  of  a wart-like  glandular  appearance.  The  largest  show 
thick  black  or  brownish  crusts , which  being  removed , an  ulcerated  surface  ap- 
pears, with  pungent  pus-like  secretions.  On  the  nostrils  an  ulceration  goes 
deeply  into  the  tissue  of  the  skin.  Of  other  syphilitic  affections  there  is 
nothing  to  be  seen  except  swelling  of  the  submaxillary,  cervical  and 
occipital  glands. 

Without  any  preparation,  sublimate  injections  were  used.  Besides 
a good  diet,  we  ordered  small  doses  of  sweet  wine,  and  later  a bottle  of 
beer,  daily.  The  patient  withstood  the  deprivation  of  his  accustomed 
beverage  better  than  we  expected,  also  he  bore  the  injections  well.  They 
had  a brilliant  result.  So  that  after  giving  twelve  injections  (J  gr. 
subl.  each ) the  tumors  were  lessened  to  half  their  size.  After  further 
injecting  of  2J  gr.  there  was  hardly  anything  left  of  the  tumors.  The 
patient  was  rather  pale,  but  felt  quite  well. 

ULCEROUS  EXANTHEM. 

To  the  latter  period  of  lues  belong  those  skin  processes 
which  come  about  by  the  ulcerative  metamorphosis  consisting 
of  vesicles  and  pustules , and  which  are  named  ecthyma  and 
rupia  syphilitica . Here,  during  the  ulcerative  process  of 
the  infiltrated  cuticle,  under  the  exposed  epidermis  are  formed 
those  ulcers  with  deep  flabby  borders,  being  always  repro- 
duced by  a concatenated  after-development.  This  disease 
resulting  from  extremely  bad  nutrition,  does  not  always 
contraindicate  a hypodermic  medication  with  a medicine 
which  has  always  been  reproached,  not  only  with  producing 
an  analogous  cachexia,  but  of  producing  ulcers  similar  to 
those  described  above ; but  I can  say  with  satisfaction,  that 
all  patients  laboring  under  similar  skin  affections,  and  their 
number  has  not  been  very  small,  have  been  healed  with  in- 
jections of  sublimate,  and  the  cure  has  been  effected  in  a 


148 


SYPHILITIC  SKIN  AFFECTIONS. 


relatively  short  time.  Of  a stay  of  months  or  even  years, 
as  I have  seen  in  other  hospitals,  and  as  patients  have  re- 
lated, was  never  the  case  with  us.  After  'the  use  of  only  a 
few  small  doses  of  the  sublimate,  the  characteristic  pyrimidal, 
thick  brownish  black  colored  crusts,  dried  up;  generally 
beginning  on  the  periphery,  and  soon  after  healing  the  mid- 
dle, since  here  the  crusts  were  the  thicker.  At  the  same 
time  the  livid  redness  disappears,  which  encircles  the  infil- 
trations of  the  ulcers.  It  is  generally  the  consequence  of  a 
venous  stasis  which  escapes  ulcerative  destruction  and  thus 
hinders  the  further  ulceration  of  the  skin.  By  lessening 
the  secretion  of  the  ulcerated  bases,  and  the  presence  of  im- 
paired material,  the  crusts  become  dryer,  soon  consolidate 
and  mostly  dry  up,  leaving  only  a trifling  moist,  yet  hyper- 
plasic  pale  red  color.  To  arrest  this  cellular  proliferation 
of  the  granulated  tissue  is  the  object  of  further  injection. 

In  contrast  to  that  very  often  rapidly  healing  process 
sometimes  these  ulcerous  crusts  show  a remarkable  obstinacy, 
not  only  the  larger,  but  sometimes  the  very  diminutive  ones. 
Occasionally  reproduction  begins  in  the  form  of  single  fresh 
small  pustules.  They  sometimes  deceive  the  surgeon  in  their 
first  appearance,  he  taking  them  for  a mercurial  exanthem 
consequent  upon  the  injection  of  the  sublimate;  but  very 
soon  they  heal,  thus  showing  the  groundlessness  of  his 
suspicion. 

In  the  following,  I shall  present  some  of  the  species 
“ rupia  syphilitica”  which  maybe  taken  as  an  evidence, 
that  even  this  obstinate  form  of  tertiary  syphilis  gives  way 
quickly  to  the  injection  treatment. 

Case  48. — Carl  P.,  shoemaker,  28  years  old,  of  healthy  and  strong 
build,  but  of  very  pale  appearance,  was  received  January  29th  into  the 
Charite  wards.  The  following  is  his  deposition:  suffered  about  four 


ULCEROUS  EXANTHEM. 


149 


years  ago  with  gonorrhoea,  which  soon  disappeared,  after  using  injec- 
tions. Three  months  ago,  a few  weeks  after  his  last  coitus,  he  saw  an 
ulcer  on  the  prepuce.  Used  for  it  borax  and  tar,  with  fasting.  Two  or 
three  weeks  subsequently,  the  now  existing  exanthem  made  its  appear- 
ance. He  dieted  himself  again,  took  sulphur  internally,  and  externally 
used  a wash  of  borax,  and  later,  tar  soap  : but  the  eruption  did  not  dis- 
appear. Some  five  days  ago,  hoarseness  and  weak  eyes  presented  them- 
selves. Status  prsesens : On  the  prepuce  can  be  felt  a large  and  very 
hard  ulcer  of  the  size  of  a walnut.  The  whole  body  is  covered  with  a 
polymorphous  exanthema,  consisting  of  papulous  and  squamous  efflo- 
rescences which  are  intermingled  with  a greater  number  of  vesicles  and 
pustules.  The  vesicles  are  of  the  size  of  a lentil  and  close  together  in  the  re- 
gion of  the  shoulder-blade  and  on  the  abdomen.  There  are  a few  on  the  face 
and  forehead  with  pustules  of  the  size  of  a pea.  On  the  left  eye  a specific 
iritis  in  a mild  degree  has  developed  itself , which  after  using  atropia  showed 
some  adhesions. 

Laryngoscopic  inspection  revealed  redness  and  swelling  of  the  mu- 
cous membrane  of  the  vocal  cords  besides  single  superficial  erosions  on 
the  mucosa  of  the  anterior  angle  of  the  glottis. 

We  used  the  subcutaneous  medication,  beginning  with  -jL  gr.  doses. 
The  five  following  doses  were  about  J gr.  each,  and  the  last  five  i gr. 
each,  so,  that  for  complete  cure,  3f  gr.  of  sublimate  were  used.  The 
healing  occurred  in  the  following  manner:  After  the  fourth  injection 
(about  If  gr.  sublimate  being  given)  part  of  the  vesicles  on  the  back 
were  dried  up  and  another  part  were  metamorphosed  into  a puriform 
condition.  After  the  eighth  injection  the  pustulous  exanthem  dried  up 
in  crusts,  which  pealed  off  shortly  after,  leaving  only  superficial  ero- 
sions of  the  cuticle,  which  quickly  cicatrized.  It  was  singular  that 
after  the  described  healing  of  these  pustules,  others  were  freshly  devel- 
oped but  very  soon  dried  up  again. 

After  the  fourth  injection  the  subjective  appearance  of  the  iritis  was 
somewhat  bettered,  and  the  dilitation  of  the  pupil  was  normal,  but  the 
vessels  of  the  sub-conjunctiva  were  so  congested  that  we  were  compelled 
to  apply  eight  leeches.  There  was  noticeable  no  stomatitis  until  after 
the  fourth  injection,  which  resulted  in  salivation  from  the  too  frequent 
injections,  so  that  an  interruption  in  the  treatment  of  ten  days  occurred. 
The  stay  of  the  patient  in  the  hospital  consisted  altogether  of  twenty- 
four  days. 

Case  49. — Philip  W.,  farmer,  26  years  old,  received  into  the  Charite 

13* 


150 


SYPHILITIC  SKIN  AFFECTIONS. 


Oct.  26,  1867.  He  says  that  six  years  ago  he  had  a chancre  and  bubo, 
for  which  he  used  laxatives  for  quite  a time.  May,  1866,  he  contracted 
chancre  again,  and  was  then  homoeopathically  treated.  But  in  June 
he  noticed  an  eruption  on  the  skin,  for  which  he  first  used  a sweat  cure, 
and  afterwards  an  inunction  cure,  taking  altogether  eight  weeks.  But 
seeing  that  his  health  did  not  improve  he  came  to  our  hospital. 

Status prsesens : On  the  prepuce  there  is  an  indurated  cicatrix  and  a 
slight  erosion.  On  the  surface  of  the  left  cheek  we  see  an  infiltration  of  the 
size ■ of  a penny , consisting  of  small  confluent  papules.  Similar  erosions  we 
find  on  the  forehead,  but  here  they  are  covered  with  yellow , green , impetiginoid 
crusts.  The  skin  of  the  scalp  shows  a greater  number  of  deep-seated  ulcers , 
which  are  only  partly  covered  by  black , brown , moist  crusts.  On  the  right 
arm  there  are  four  elevated  red  infiltrations , of  the  size  of  a penny , which  show 
on  their  periphery , more  especially , thick  crust  formations.  Similar  efflores- 
cences, with  a pronounced  rupia-like  characteristic  ulceration , are  on  the  right 
thigh  and  lower  extremities.  The  very  thin  dry  hair  can  be  easily  pulled 
out.  The  lymphatic  glands  of  the  right  inguinal  region  are  more 
swelled  than  the  left,  and  still  more  tumefied  are  the  right  cervical  and 
left  submaxillary. 

The  injections  had  the  following  effects  : after  the  tenth  injection, 
(amounting  to  2 gr.  of  subl.),  the  erosions  on  the  prepuce  and  its  indu- 
rations had  disappeared ; the  crusts  on  the  body  and  head,  were  gone, 
and  the  slightly  elevated  places  were  infiltrated,  as  evidenced  by  the 
touch,  but  were  healed  in  the  middle.  After  fifteen  injections  (3  gr. 
subl.  being  used),  the  infiltrations  were  much  softer.  After  twenty-five  in- 
jections slight  stomatitis  occurred,  but  nevertheless,  the  patient  in  a few 
days  was  sent  away  cured. 


Case  50. — Johanna  S.,  29  years  old,  wife  of  a cutler,  was  received 
into  the  hospital  March  7tli,  1867.  Patient  says  but  a very  little  about 
her  disease.  She  remembers  having  sore  places  on  her  genitals  several 
times.  The  present  sores  she  had  not  particularly  noticed.  The  erup- 
tion on  the  skin  dates  back  three  months  ago,  and  she  states  positively 
that  she  never  used  any  medication. 

Status  prsesens : The  patient  is  very  much  emaciated,  of  a pale,  dirty, 
sallow  color,  cachectic  habitus.  On  the  left  labium  min.  there  is  a 
superficial  erosion.  A great  part  of  the  surface  of  the  body , especially  the 
back , chest , the  upper  and  lower  extremities , are  covered  with  a convolution  of 
vesicles  and  pustules , grouped  together , with  here  and  there  papules  covered 


KNOTTY  SYPHILOID. 


151 


with  a thin  layer  of  scab.  In  the  right  scapular  region  are  rupia  crusts  of 
the  size  of  a penny  and  pyramidal  in  shape.  In  removing  them,  the  bleed- 
ing surface  appears  deeply  ulcerated.  On  the  hand  are  ulcers  covered  with 
crusts  which  have  taken  on  an  impetiginous  character.  Ulcerations  of  the 
size  of  a Mexican  dollar  are  visible  on  the  lower  part  of  the  calf  of  the  left 
leg , with  livid , flabby)  easy  bleeding  borders , encircled  by  varicose  veins. 
Between  the  third  and  fourth  toe  on  the  right  foot,  there  is  quite  a 
large  ulceration  with  a fetid  smell  and  covered  with  a dirty  secretion 
of  a condylomatous  character.  In  the  left  eye  there  is  a well  marked 
iritis  with  several  adhesions  of  the  retina.  The  left  tonsil  is  partly  de- 
stroyed by  ulceration.  The  mucous  membrane  of  the  larynx  is  red  and 
swollen  throughout.  In  the  middle  of  both  vocal  cords,  gray-white 
patches  are  to  be  seen,  produced  probably  by  an  ulcerative  detritus. 
The  inguinal  glands  are  but  slightly  swollen,  but  the  cervical  are  very 
much  enlarged. 

I used  subcutaneous  injections  of  sublimate  with  iodide  of  potassium 
for  about  a week,  but  left  the  latter  medicine  out  of  the  treatment  at 
this  time.  The  first  day  we  injected  J gr.  of  sublimate  in  one  dose  in 
order  to  combat  energetically  and  quickly  the  iritis.  Already  on  the 
next  day  the  gums  were  very  much  swollen  and  easily  induced  to 
bleed.  The  eye  was  somewhat  better.  After  the  second  injection  of  \ 
gr.  of  sublimate,  the  patient  complained,  not  only  of  the  prodromes  of 
salivation,  but  also  of  mercurial  ulcerations  on  the  mucous  membrane 
of  the  cheek  and  borders  of  the  tongue.  Chlorate  of  potassa  was  used 
both  externally  and  internally  for  this,  we  stopping  the  treatment  for 
three  days. 

The  iritis  had  nearly  subsided  and  only  small  .adhesions  remained 
on  the  borders.  By  the  following  injections  of  J'gr.  and  sometimes  J 
gr.  per  dose,  the  above  detailed  symptoms  vanished  entirely,  so  that 
we  used  in  the  whole  seventeen  injections  of  4f  gr.  of  sublimate.  In 
place  of  the  crust-like  exanthem  intensely  brown-colored  pigment 
patches  appeared. 


KNOTTY  SYPHILOID.* 

I discuss  now  a syphilitic  formation  of  a disease  which  is, 
especially  in  a morphological  sense,  of  the  greatest  import- 
ance, because  a question  has  to  be  decided  here,  which  in 

* Knoten  Syphilid. 


152 


SYPHILITIC  SKIN  AFFECTIONS. 


spite  of  our  best  authors  on  anatomy  and  dermatology,  is 
yet  an  object  of  a very  spirited  controversy — I mean  the 
lupus  syphiliticus . 

Among  these  authors  there  are  some  which  go  so  far  as  to 
assert  that,  between  lupus  and  syphilis  acquisita,  all  and 
every  feature  is  radically  different. 

They  particularly  assert  “ that  sufficient  signs  are  wanting 
by  which  the  variety,  lupus  syphiliticus,  can  be  distinguished 
from  lupus  idiopathicus.  In  none  of  the  cases  of  lupus, 
they  say,  in  which  an  autopsy  was  made,  was  a combination 
with  syphilitic  affections  of  internal  and  external  organs 
distinctly  found.  The  very  slow  progress  of  the  lupus, 
sometimes  existing  for  years ; the  limited  seat  of  the  same 
in  most  cases ; the  entire  painlessness ; the  small  participa- 
tion of  the  nutritive  functions  ; the  absence  of  cachexia  and 
all  swelling  of  the  lymphatic  glands  ; the  want  of  regularity  ; 
and  lastly  the  smallness  of  the  knots,  compared  with  their 
relatively  long  duration,  and  the  non-appearance  of  the 
caseous  metamorphosis  incident  to  gummy  tumors ; all 
certainly  speak  most  emphatically  against  their  identity. 
Besides,  very  many  defenders  of  the  syphilitic  nature  of  the 
lupi,  themselves  acknowledge  the  anti-syphilitic  treatment 
without  any  result.” 

I am  induced  by  these  remarks  to  make  the  following 
observations : — 

1.  I first  have  to  point  out  the  fact  that  between  the  spe- 
cific and  idiopathic  eruptions  of  the  skin — as,  for  instance, 
between  the  syphilitic  macula  and  the  ordinary — no  histo- 
logical difference  till  now  has  been  discriminated.  And  so 
it  is  between  the  small  knots  of  the  lupus  idiopathicus  and 
those  of  the  knotty  syphiloid.  No  histological  difference 


KNOTTY  SYPHILOID. 


153 


has  been  found  in  them,  both  formations  belonging  to  what 
Virchow  calls  “ granulation  tissue.” 

2.  As  to  the  assertion  that  in  no  case  of  lupus,  where 
autopsy  was  performed,  were  other  known  syphilitic  diseases 
of  internal  organs  found ; I must  say  that  my  clinical  mate- 
rial provided  me  with  several  cases  in  which,  without  doubt, 
syphilitic  affections,  as  rupia,  tophi,  ulcerations  in  the  cavity 
of  the  mouth,  have  been  combined  with  lupus  affection  of 
the  skin.  I have  seen  during  the  last  four  years  about 
twenty  such  cases,  and  at  present  I have  in  my  wards  three 
remaining  patients  of  this  kind.  I took  occasion  to  present 
one  of  them  to  several  colleagues. 

3.  The  chronological  proportion  is  also  in  favor  of  our 
view.  Specific  lupus  never  occurs  in  the  beginning  of  the 
syphilitic  disease,  where  it  might  be  taken  as  a coincidence, 
but  it  always  appears  as  the  last  link,  in  the  latest  phases 
of  the  development  of  constitutional  syphilis,  being  preceded 
by  a number  of  more  or  less  severe  processes,  as  maculo- 
papulous  syphiloid,  iritis,  rupia,  sarcocele  syphilitica,  and 
especially  syphilitic  affections  of  the  bone. 

4.  Concerning  the  specific  alterations  of  the  lymphatic 
glands  not  seen  by  some  authors,  I,  on  the  contrary,  can 
point  out  clearly,  in  several  cases,  enlargements  and  indura- 
tions ; and  further  I have  to  remark  that  often  in  the  latter 
stages  of  syphilis,  the  lymphatic  glands  are  not  only  reduced 
to  their  normal  size,  but  even,  in  consequence  of  atrophy, 
are  hardly  to  be  found,  being  below  the  normal  size,  as 
Virchow  has  shown  it  to  be,  in  a similar  way,  with  the  seba- 
ceous glands  of  the  tongue. 

5.  As  to  the  assertion  that  anti- syphilitic  treatment  has 
been  of  no  avail  against  lupus  syphiliticus,  I will  say  in 
opposition  to  it,  that  some  of  our  medical  literature  mentions 


154 


SYPHILITIC  SKIN  AFFECTIONS. 


such  cases,  and  besides,  the  subcutaneous  injection  method 
which  I instituted  with  a number  of  cases  (from  twenty  to 
twenty-four)  in  our  hospital  has  never  failed. 

6.  The  assertion  that  the  small  participation  of  the  nutri- 
tive functions  and  the  want  of  all  cachectic  symptoms,  speak 
against  the  syphilitic  nature  of  lupus,  is  modified  in  two 
ways  by  my  experience.  On  the  one  hand,  a great  number 
of  patients,  who  are  suffering  under  very  active  processes  of 
syphilis,  seated  on  circumscribed  localities,  enjoy  relatively 
good  health  and  appearance ; on  the  other  hand,  a part  of 
my  patients  affected  with  lupus  syphiliticus  show  sufficient 
symptoms  of  a deep-going  cachexia. 

7.  It  is  granted  that  lupus  idiopathicus  has  its  seat  in  the 
face  mostly,  just  as  lupus  syphiliticus  has  its  seat  generally 
on  the  back  and  extremities.  But  not  only  are  cases  known 
and  referred  to  by  different  authors  where  lupus  appeared 
not  only  in  the  face  but  also  on  the  extremities,  and  I, 
myself,  and  several  other  observers  have  had  occasion  to  see 
lupus  syphiliticus  seated  on  the  face,  where  it  generally  does 
not  appear,  and  on  the  nose,  forehead  and  cheeks. 

8.  I will  not  make  any  remark  on  the  “ painlessness’ ’ 
since  a great  number  of  syphilitically  affected  cases  often 
run  a painless  course. 

9.  Concerning  the  last  point,  that  the  syphilitic  knotty 
exanthema  never  enters  into  a caseous  metamorphosis,  as  is 
the  case  with  lupus  idiopathicus,  this  circumstance  alone 
will  speak  for  it.  As  in  all  other  exanthemata,  we  must 
take  a special  species  of  lupus  syphiloid,  which  must  be 
distinguished  from  idiopathic  lupus. 

From  a number  of  nearly  twenty  cases  lying  before  me,  I 
take  the  following  case  of  lupus  syphiliticus,  which  was  so 
typical  in  its  total  impression  and  its  single  appearance,  and 


KNOTTY  SYPHILOID. 


155 


was  such  a striking  example  of  the  disease,  that  I introduced 
the  patient  to  Professor  Virchow's  notice. 


Case  51. — Wilhelm  K.,  a stone  mason,  thirty  years  old,  originated 
from  a family  in  which  a dyscrasic  habitus,  especially  tuberculous  and 
lupus,  has  never  been  noticed..  Married  six  years  ago,  but  has  had  no 
children,  his  wife  being  reported  in  good  health.  He  was  till  that  time 
healthy  and  robust,  but  became  sick  for  the  first  time  in  the  year  1858, 
with  a glandular  abscess  on  the  left  side  of  the  neck.  There  yet  can  be 
seen,  above  the  insertion  of  the  musculus  sterno-cleido-mastoideus  on 
the  sternum,  a cicatrix  of  a star-like  form.  Eight  years  ago  the  patient 
contracted  a chancre  on  the  penis,  which,  after  a local  treatment  and 
internal  medication  with  pills,  probably  containing  mercury,  seemed  to 
heal  after  about  four  weeks.  But  a year  later,  already,  ulcers  in  the 
pharynx  made  their  appearance,  which,  as  reported,  have  been  rather 
deep-seated,  and  for  which  a long  sarsaparilla  sweat  cure  was  ordered. 
This  had  a result  lasting  only  about  a year,  so  that  a repetition  of  the 
treatment  was  necessary.  The  ulcers  now  present  on  the  face,  on  the 
scalp,  and  especially  on  the  nose,  appeared,  as  the  patient  said,  in  1864, 
for  which,  in  our  hospital,  iodide  of  potassium  and  sulphur  baths  were 
ordered,  with  good  effect.  But  the  healing  was  not  complete  and  did 
not  last  very  long,  the  present  diseased  condition  gradually  coming  on. 

Status  proesens , December  21st,  1868  : Patient  has  flabby  muscles, 
pale  complexion,  and  very  dry  skin  ; face  very  much  disfigured  by  cicatriza- 
tions and  deep  loss  of  substance . The  scars  extend  partly  over  the  cheeks , 
chin  and  forehead , having  a more  or  less  rounded , oblong  formation . The 
roundness  of  the  cicatrix  shows  a clearly  defined  atrophy  of  the  cuticle , having 
the  character  which  is  generally  manifested  by  the  cicatrized  ulcers  developed 
by  ulcerative , broken-down  knotty  lupus.  The  long  cicatrices  have  a star-like , 
bluish-white  appearance. 

The  left  eyelids,  already  retracted  in  their  tissue  by  the  great  cicatrices, 
are  greatly  swollen  and  firmly  stretched  over  the  eye,  so  that  the  latter 
was  neither  completely  shut  nor  widely  open.  By  such  a state  of  lag- 
opthalmus,  the  cornea  is  obscured,  and  exudations  are  going  on  that 
have  nearly  impaired  the  vision  of  this  eye.  On  the  nose  the  cartilages 
of  the  nostrils  are  destroyed , more  extensively  on  the  left  side.  The  point  and 
top  of  the  nose  and  a greater  part  of  the  septum  narium  are  wanting , from  the 
effect  of  a deeply-eating  ulcer , it  being  nearly  two  inches  long  and  one  ahd  a 
half  inches  wide , having  the  characteristic  appearance  of  idiopathic  lupus.  It 


156 


SYPHILITIC  SKIN  AFFECTIONS. 


extends  down  to  the  upper  lip,  of  which  a part  is  ulcerated  away.  The 
remaining  part  of  the  upper  lip  is  very  much  infiltrated,  like  lupus 
hypertrophicus,  showing  the  well-known  livid-red  color.  On  the  scalp 
in  the  vicinity  of  the  parting  of  the  hair,  are  crustous  ulcerations 
covered  with  amber-colored  horny  excrescences,  and  partially  with 
red-brown  crusts  as  they  appear  in  ecthyma  and  rupia.  Both  tibiae 
have  on  their  surfaces  large  hyperostoses,  causing,  nights  especially, 
severe  boring  pains. 

The  left  testicle  is  of  the  size  and  form  of  a large  pear,  hard  to  the 
touch,  showing  in  the  middle  and  on  the  border  of  the  epididymis  a 
knotty  circumscribed  induration,  which  was  glued  anteriorly  to  the 
inflamed,  red,  swollen  and  painful  testicles.  In  the  cavity  of  the  mouth 
a total  destruction  of  the  left  tonsil  and  the  anterior  roof  of  the  palate 
is  visible,  in  which  region  is  stretched  a small,  ribbon-like,  red  strip  of 
mucous  membrane,  extending  from  the  uvula  to  the  side  wall  of  the 
pharynx.  The  right  tonsil  and  uvula  are  intact.  The  lymphatic  glands, 
especially  in  the  cubital  regions,  are  slightly  swollen. 

The  patient  is,  on  account  of  his  previously  described  condition  and 
the  last  preceding  treatment,  in  a very  weak  state.  Objections  could 
consistently  be  raised  against  a common  mercurial  treatment ; never- 
theless, we  began  with  him  the  injection  cure  immediately,  with  which 
the  strength  of  the  patient  gradually  improved  and  the  detailed  symp- 
toms lessened. 

The  dolores  osteocopi  (pain  in  the  bones)  was  the  first  to  leave  him, 
and  consequently,  by  ability  to  get  his  rest  at  night,  the  patient  gained 
strength.  The  swelling  on  the  left  scrotum,  together  with  the  inflam- 
mation and  pain,  already  had  subsided,  after  the  use  of  J gr.  of  subli- 
mate ; as  also  had  the  consistency  of  the  scrotum  likewise  diminished. 
The  ulcers  of  the  face  became  cleaner  and  cicatrized  from  the  periphery 
towards  the  centre;  so  that,  after  the  further  injection  of  2J  grs.  of 
sublimate,  they  were  reduced  to  nearly  half  their  original  size. 

Ulcerations  on  the  nose  and  lips  were  cured  after  using  4 grs.  of  sub- 
limate. The  thick  ulcers  on  the  scalp  showed  the  greatest  resistance, 
and  they  were  healed  only  after  the  use  of  grs.  of  sublimate.  The 
cure  then  could  be  looked  upon  as  complete,  but  still  we  used  1 gr. 
more.  The  duration  of  our  treatment,  with  the  frequent  interruptions 
on  account  of  salivation,  lasted  three  and  a half  months. 


As  in  the  above  described  case,  the  following  showed  a 


KNOTTY  SYPHILOID. 


157 


still  more  brilliant  result  of  the  subcutaneous  method.  In 
spite  of  all  kinds  of  medication  during  a ten  months’  sick- 
ness, syphilis  could  not  be  stayed  in  its  ravages.  Not  only 
was  the  patient  emaciated  to  a skeleton  almost,  by  the  ulcers 
covering  so  much  of  the  surface  of  the  body,  death  was  also 
almost  unavoidable,  on  account  of  the  fact  that  the  syphilitic 
process  had  drawn  the  kidneys  into  complication. 

Case  52. — Augusta  Fiehl,  twenty  years  old,  of  quite  a healthy  con- 
stitution, without  any  hereditary  disposition  to  constitutional  affec- 
tions, had,  at  the  time  of  her  admission  into  the  Charite,  January  23, 
1865,  very  hard  erosions  on  the  labia  majora,  accompanied,  shortly 
afterwards,  with  broad  condylomes  on  the  labia  minora  and  majora, 
plicae  femorales  and  tonsils.  The  patient  used  then  a sarsaparilla  sweat- 
cure,  without  staying  the  progress  of  the  lues.  On  the  contrary,  after 
the  course  of  a week,  roseola  patches  were  formed — in  the  beginning, 
only  on  the  thorax  and  upper  extremities  ; later,  in  other  different 
regions.  Besides,  a papulous  syphiloid  was  also  formed,  whose  efflor- 
escences were  very  soon  developed  on  their  points  into  small  scales. 

Not  very  long  after,  fever  set  in,  with  a temperature  of  the  body  of  39° 
Cel.,  and  with  a frequency  of  the  pulse  reaching  100  per  minute;  and  several 
vesicles  were  formed,  some  soon  becoming  pustules,  and  some  forming  into 
vesicles  like  those  in  pemphigus.  The  former  of  these  were  situated  more 
particularly  in  the  bend  of  the  lower  and  upper  extremities,  especially 
in  the  fossa  cubitalis  and  poplitea  ; the  latter  were  mostly  on  the  ante- 
rior part  of  the  neck.  Very  suddenly  pain  appeared  in  the  right  eye, 
extending  to  the  depth  of  the  orbit,  and  of  a boring  character.  Intense 
iritis,  with  great  photophobia  and  flowing  of  tears,  followed.  By  an  en- 
ergetically instituted  antiphlogistic  treatment,  consisting  of  inunction 
of  unguentum  hydrag.,  with  opium,  atropine,  leeches,  &c.,  the  iritis  of 
the  right  eye  disappeared,  but  shortly  afterwards  the  same  iritic  process 
was  developed  in  the  left  eye,  which  required  a still  more  energetic  use  of 
the  same  antiphlogistic  treatment  for  effecting  a cure. 

During  this  intercurrent  episode  with  the  eye,  pustulous  efflorescences 
of  the  skin  began  to  be  very  prolifically  developed,  increasing  in  size  on  ac- 
count of  confluency  and  destruction  of  the  infiltrated  ulcerations.  The 
always  deeper-going  ulcerations  did  reach  not  only  the  subcutaneous  cellular 
tissue,  but  even  the  fascia  and  muscles  were  reached  and  drawn  into  complied - 
14 


158 


SYPHILITIC  SKIN  AFFECTIONS. 


tion.  Especially  was  this  the  case  in  the  region  of  the  os  sacrum  and 
the  extremities.  The  ulceration  on  the  os  sacrum  was  particularly  distin- 
guished by  its  large  circumference , it  being  six  inches  long  and  three  inches 
wide.  Here  the  underlying  bone  could  be  plainly  felt  with  the  probe.  A 
smaller,  more  round-shaped,  but  as  deeply-going  ulceration  was  situ- 
ated on  the  calf  of  the  right  leg,  and  the  periosteum  of  the  tibia  could 
be  clearly  seen  in  a circumscribed  place. 

To  combat  the  above  detailed  condition,  we  used  very  many  medica- 
tions for  months  without  any  results.  Besides  the  repetition  of  the 
already  mentioned  sarsaparilla  sweat-cure,  which  lasted  for  a few 
weeks,  inunction  and  different  baths  and  ingredients  in  the  same  were 
used.  Later,  sublimate  baths  and  the  wet  sheet  were  employed,  accord- 
ing to  Priesnitz.  Internally  we  used  iodide  of  potassium ; and  lastly, 
solutio  arsenicalis  Fowleri. 

During  the  treatment,  we  used,  for  strengthening  the  system,  quinine, 
iodized  iron,  and  later,  cod-liver  oil. 

With  this  treatment,  the  patient  was  emaciated  to  almost  a skeleton, 
in  the  course  of  nine  months.  In  this  cachectic  state  I found  her  when  I 
tried  for  the  first  time  on  her  my  injection  treatment.  She  was  so  weak 
that  she  was  compelled  to  keep  in  bed  continually,  not  being  able  to 
raise  herself  for  a precise  examination  into  her  condition.  In  order  to 
see  the  skin  affections,  during  my  clinical  lecture,  I was  obliged  to  have 
assistants  raise  her  from  side  to  side.  The  ulcerations  secreted  a 
profuse,  pungent,  purulent  matter.  On  the  face  there  was  a lupus-like 
syphiloid.  On  the  arms , layers , in  pyramidal  formations , placed  over  each 
other , could  be  seen)  which  were  composed  of  thick  crusts  of  dark  brown  choc- 
olate-colored appearance , under  which  purulent  ulcers  were  situated. 

TJrine  was  very  albuminous — its  specific  gravity , straw  color , all 
pointing  to  severe  renal  disease. 

Prognosis,  under  such  circumstances,  could  but  be  very  unfavorable  ; 
because  all  sorts  of  treatment  had  proved  of  no  avail.  The  weakness 
of  the  patient  and  the  impending  kidney  affection  were  a contra-indication 
to  every  new  energetic  treatment. 

But,  notwithstanding  all  that,  I concluded  to  use  with  this  patient 
injections  of  sublimate,  on  account  of  the  old  adage  u Melius  anceps 
remedium)  quam  nullum  in  casibus  desperatisT  Because  of  the  great  pros- 
tration, I began  the  treatment  cautiously,  with  very  small  doses ; and 
seeing  no  bad  symptoms  arise,  but,  on  the  contrary,  a very  slight  and 
hardly  perceptible  improvement,  I began  to  give  larger  doses. 


GUMMATA  OF  THE  CELLULAR  TISSUE. 


159 


The  great  difficulty  with  the  injection  was,  that  the  whole  body  was 
so  covered  with  broad  and  deep  ulcerations  that  I had  but  very  little 
space  of  sound  and  healthy  skin  where  I could  make  my  punctures. 
Another  difficulty  I found  in  the  dislike  of  the  patient,  who  refused,  and 
seemingly  with  a perfect  justice,  to  undergo  anew  a painful  treatment, 
since  all  our  endeavors  had  failed  in  restoring  her  health.  But  by  and 
by  the  feeling  of  the  patient  gave  way  to  a better  spirit,  on  account  of 
the  improvement  in  her  disease. 

The  result  was  indeed  for  me,  and  for  all  who  witnessed  it,  a striking 
one.  I used  about  one  hundred  and  fifty  injections,  amounting  to  a 
total  of  about  15  grs.  of  sublimate,  and  the  method  being  quite  new 
then,  the  case  made  considerable  propaganda  for  the  subcutaneous 
treatment.  A large  circle  of  my  pupils  followed  the  case  with  apparent 
interest,  seeing  how  changed  the  patient  became.  She  finally  could  be 
discharged  entirely  cured , having  quite  a healthy  countenance , herself  being 
astonished  at  the  result. 

, After  a year,  A.  F.  returned  again,  for  a short  time,  to  the  Charite, 
on  account  of  some  small  ulcers,  which  appeared  on  the  right  forearm. 
They  quickly  vanished  with  the  administration  of  a few  injections,  and 
the  very  healthy  and  almost  blooming  appearance  of  the  patient  was 
really  wonderful  to  us,  who  had  seen  her  in  her  ghastly  and  emaciated 
condition. 

GUMMATA  OF  THE  SUBCUTANEOUS  CELLULAR  TISSUE. 

We  may  consider,  very  properly,  those  gummata  which 
develop  themselves  in  the  deeper  cellular  tissue , as  a differ- 
ent species  from  the  above-described  knotty  syphiloid.  They 
are  distinguished  from  them  first  especially  by  their  greater 
size,  which  comes  about  chiefly  on  account  of  their  situation 
in  the  subcutaneous  cellular  tissue,  where  they  find  in  the 
net-like  texture  more  room  for  development  than  the  lupous 
knots  which  are  imbedded  in  tense,  unyielding  layers  of 
cuticle. 

Generally  these  gummous  formations  first  commence 
during  the  latest  phase  of  lues,  and  mostly  as  final  links  of 
the  syphilitic  dyscrasia.  But  contrary  to  this  general  obser- 


160 


SYPHILITIC  SKIN  AFFECTIONS. 


vation,  I observed  this  appearance  in  two  cases  rather 
sooner. 

In  one  of  these  cases,  which  might  properly  be  called 
“ galloping  syphilis,”  this  affection  appeared  almost  as  a 
first  symptom  of  relapsing  syphilis,  and  accompanied  mostly 
with  orchitis  gummosa  and  rupia.  In  both  cases,  as  also  in 
those  patients  where  no  ulcerative  metamorphosis  in  the 
gummous  granulated  tumor  has  taken  place,  I succeeded  in 
complete  resorption  by  the  subcutaneous  treatment,  so  that 
neither  a scar  nor  depression  of  the  skin  remained,  and  not 
even  a discoloration  showed  the  former  seat  of  these  so  obsti- 
nate tumors. 

The  first  result  was  mostly  visible  in  the  lessened  cir- 
cumference of  the  ulcers,  the  consistency  of  them  seemingly 
increasing  in  hardness , but  time  alone  will  overcome  that, 
and  complete  restoration  crowns  the  work.  It  may  be  ex- 
plained thus  : that  with  resorption,  the  softer  contents  of  the 
ulcer  began  to  heal,  and  only  later  is  it  the  case  with  the 
peripheric  surroundings  which  have  a more  or  less  sclerotic 
taint. 

It  was  singular  to  notice  that  the  nearer  lymphatics  became 
irritated  and  inflamed , being  enlarged , reddened  and  painful 
to  the  touch . It  may  be  possible  that,  absorption  in  the 
lessened  gummy  tumor  carries  along  the  detritus,  and  this 
may  be  the  cause  of  the  irritative  symptoms  in  the  lymphatics. 

But  not  always  were  the  gummata  in  patients  in  a yet  in- 
tact state.  Very  often  they  presented  thin  open  ulcers , 
tvhich  sprung  from  an  ulcerative  metamorphosis . 

The  ulcerative  process  may  here  be  traced  in  most  cases 
to  a mechanical  origin,  and  it  seems  to  be  induced  and 
favored  by  the  neighborhood  of  bones,  especially  epiphyses, 
narrow  folds  of  skin,  &c.,  which  may  be  easily  irritated.  As 


GUMMATA  OF  THE  CELLULAR  TISSUE. 


161 


in  diseases  of  the  larynx  and  pharynx,  we  must  here  also 
be  careful  not  to  force  the  injection  or  prolong  it.  On  the 
contrary,  it  is  necessary  to  institute  here  a surgical  treat- 
ment. 

The  quantity  of  sublimate  necessary  for  the  described 
gummous  tumor  is  generally  very  large.  In  lupous  ulcer 
sometimes  3 gr.  were  sufficient,  but  in  the  gummata  from  6 
gr.  to  10  gr.  of  sublimate  on  the  average  were  needed,  but 
cases  occur  in  which  even  this  amount  must  be  increased. 

Case  53. — Max.  L.,  twenty-two  years  old,  a cigar  maker,  was  received 
into  the  Charite  Hospital  October  9,  1868.  Patient  says  he  is  of  a healthy 
family,  and,  with  the  exception  of  the  ordinary  diseases  of  childhood, 
he  was  well  up  to  his  thirteenth  year.  In  the  following  year  he  suffered 
considerably  with  glandular  swellings  in  the  neck,  which  disappeared 
with  the  use  of  cod  liver  oil. 

The  patient  was  infected  eleven  months  ago  with  chancre,  in  London, 
which  seemed  so  insignificant  that  he  consulted  no  doctor.  Only  five 
months  ago  his  present  ailment  began,  but  medical  aid  was  of  no  avail. 
The  medication  was  a botanic  one,  as  the  attending  physician  did  not  think 
it  justifiable  to  use  any  mercurial  preparation , on  account  of  the  ulcerative 
character  of  the  rupia  which  seemed  to  spread  rapidly . But  on  the  contrary, 
as  the  ulcers  enlarged  more  and  more,  healing  of  them  was  despaired 
of,  and  his  physicians  advised  him  to  leave  England,  and  go  back  to  Ger- 
many, partly  on  account  of  the  climatic  change  which  might  bring 
about  a better  state  of  things. 

Status  prsesens:  Patient  is  very  much  emaciated,  of  pale  complexion, 
blonde  hair,  cachetic  appearance,  and  of  a very  delicate  constitution. 
I found  him  lying  in  bed  at  my  first  visit,  he  being  unable  to  move,  on 
account  of  the  great  pain  induced.  Examination  revealed  rupia  crusts 
on  both  fore  arms,  on  the  forehead , the  scalp , on  the  back  and  lower  extremities , 
of  the  size  of  a penny  up  to  the  size  of  a silver  dollar.  Beneath  the  thick  brown 
crusts , deep  seated  ulcerations  are  to  be  seen  covered  over  with  pus.  On  both 
tibise  we  find  diffuse,  painful,  gummous  swellings,  having  an  elastic  consistency. 
Similar  swellings  are  on  the  left  clavicle , especially  at  the  acromial  end.  On 
the  left  of  the  scrotum  we  can  feel  small  tumors , but  on  account  of  too  great 
sensitiveness  they  cannot  be  plainly  made  out.  After  a few  days , examination 

14* 


162 


SYPHILITIC  SKIN  AFFECTIONS. 


showed  that  there  are  gummous  tumors  there  of  the  size  of  a hazelnut . In  the 
subcutaneous  tissue  of  the  right  sternal  region  in  the  vicinity  of  the  nipple , and 
on  the  left  elbow , a little  above  the  olecranon , painful , gummous  ulcers  are 
found  of  the  same  size  as  above . The  lymphatic  glands  in  the  submaxil- 
lary region  are  not  swollen,  but  in  the  cervical  and  inguinal  they  are 
somewhat  enlarged.  Patient  complains  very  much  of  acute  pains  in 
the  tibial  regions  during  the  night,  and  of  an  inability  to  move  without 
experiencing  great  suffering.  On  the  inner  lamella  of  the  prepuce  there 
is  a cicatrized  place  of  the  size  of  a pea,  being  devoid  of  pigment  dis- 
coloration. It  is  not  at  all  hard  to  the  touch,  and  according  to  the 
patient,  it  is  the  seat  of  the  original  chancre. 

On  account  of  the  great  debility  of  the  patient,  I used  only  on  alter- 
nate days  the  subcutaneous  injection  in  -J-  gr.  doses.  This  being  well 
borne,  and  the  dolores  nocturni  also  abating,  we  injected  the  same  dose 
of  sublimate  daily.  Very  shortly  afterwards  the  ulcers  were  reduced  in 
size  and  depth.  The  prodromes  of  salivation  appearing,  we  were  com- 
pelled to  interrupt  the  treatment.  After  the  twenty-first  injection,  the 
patient  complained  of  a cough,  produced  by  a cold,  and  on  account  of 
a lung  complication  we  again  suspended  the  injection  for  awhile.  After 
a treatment  of  three  months  with  a few  interruptions  on  account  of 
stomatitis,  6 gr.  of  sublimate  having  been  used,  the  result  was  very 
satisfactory  on  the  described  affections,  besides  the  gummy  tumors  had 
vanished.  In  the  place  of  the  rupia  ulcers,  cicatrices  were  visible  on 
the  skin,  of  a livid  color,  a red  quilted  appearance  with  a cancroid 
character.  Patient  gained  so  visibly  and  assumed  such  a healthy 
countenance,  that  my  clinical  pupils  were  astonished  to  see  so  marked 
a change. 

About  six  weeks  after  his  discharge  from  our  hospital,  he  returned 
again  on  account  of  ulcerations  appearing.  Examination  of  the  patient 
showed  that  several  of  the  above  described  cancroid  cicatrices  were  super- 
ficially ulcerated  and  broken  down , chiefly  on  the  back  and  right  shoulder.  But 
we  were  surprised  to  find  gummata  of  the  size  of  a hazelnut , situated  about 
three  or  four  inches  below  the  axilla , and  on  the  anterior  wall  of  the  thorax , 
one  and  a half  inches  beneath  the  right  mamma.  Aside  from  this,  there  was 
nothing  abnormal  in  the  patient.  We  instituted  the  injections  again, 
beginning  with  £ gr.  doses  of  sublimate  per  day,  soon  increasing  to  J gr. 
doses. 

The  ulcers  had  already  healed  when  2 gr.  of  sublimate  had  been 
used,  but  the  gummata  disappeared  much  more  slowly.  The  glands  around 


GUMMATA  OF  THE  CELLULAR  TISSUE. 


163 

the  axilla  on  this  same  side , and  later  the  glands  about  the  nipple  were  much 
swollen  and  painful  to  the  touch.  In  addition  to  this,  a bubo  of  the  size 
of  a hen’s  egg,  made  its  appearance.  We  used  for  that  gray  mercurial 
ointment,  but  without  avail.  Neither  had  the  internal  use  of  iodide  of 
potassium  any  Result.  We  began  again,  on  this  account,  the  sublimate 
injections,  and  produced  an  entire  healing  of  the  gummata,  but  only  a 
trifling  diminution  of  the  lymphatic  glands.  But  the  sensitiveness  of 
the  patient  increased  after  the  amount  of  3 gr.  sublimate  had  been  used, 
and  we  had  to  pause.  These  injections  did  no  good ; the  swellings 
seemingly  having  no  connection  with  syphilis.  Therefore,  I concluded 
to  use  inunctions  of  iodide  of  potassium,  which  proved  to  be  just  the 
remedy. 

The  now  following  case  seems  to  have  a double  interest, 
therapeutically  and  pathologically  considered.  It  is  of  a 
pathological  interest,  inasmuch  as  a number  of  intact  gum- 
mata occurred,  and  a gummy  tumor  already  gone  into  a 
deep  ulceration,  had  involved  the  epiphysis  of  the  bones, 
while,  as  a general  rule,  they  are  situated  on  the  diaphysis. 

Therapeutically  it  is  interesting,  because  here  we  see  iodide 
of  potassium  quickly  healing  a syphilitic  ulcer  on  the  pos- 
terior wall  of  the  cavity  of  the  mouth,  but  after  a year,  a 
relapse  has  already  occurred  that  has  developed  dangerous 
symptoms,  and  yet  the  case  is  fully  cured  by  injections  of 
sublimate. 

Case  54. — Augusta  W.,  twenty-four  years  old,  married,  was  received 
into  our  hospital  October  26,  lSGT.  The  data  remembered  by  the  pa- 
tient are  rather  meagre.  She  originated  from  sound  parents,  and  says 
that,  with  the  exception  of  a slight  inflammation  of  the  eyes,  she  has 
always  been  healthy,  and  denies  that  she  ever  had  any  disease  on  her 
sexual  organs. 

Status  prsesens : Patient  of  weak  constitution,  flabby  muscles,  gracile 
habitus,  and  of  very  pale  complexion.  On  the  posterior  part  of  the 
cavity  of  the  mouth  there  is  an  ulcer  of  the  size  of  a large  penny, 
reaching  deeply  into  the  tissue  and  having  very  sharp  borders.  The 
soft  palate  is  mostly,  and  the  uvula  is  entirely  destroyed. 


164 


SYPHILITIC  SKIN  AFFECTIONS. 


We  used  daily  for  the  patient  about  50  gr.  of  iodide  of  potassium. 
On  account  of  so  great  a debility  we  prescribed  also  a weak  decoction 
of  cinchona  rubrum.  The  local  treatment  consisted  of  gargarism  of 
chlorate  of  potassa  and  painting  the  ulcerated  surface  with  nitrate  of 
silver.  Under  this  treatment  the  ulcers  cicatrized  o’ter,  so  that  the 
patient  could  be  discharged  at  the  end  of  the  sixth  week. 

That  the  iodide  of  potassium  treatment  was  only  a palliative  one  was 
shown  by  the  return  of  the  patient  in  about  one  year.  The  status  prse- 
sens  then  was  as  follows : The  described  ulcer  in  the  pharynx  remained 
cicatrized,  but  the  epiglottis  was  so  much  ulcerated  that  only  a small 
portion  of  it  remained.  The  condylus  externus  and  internus  of  the  right 
elbow  was  swollen  and  painful  to  the  touch . On  the  external  condyle  there 
could  be  plainly  felt  an  enlargement  of  the  size  of  a large  penny.  It  was 
distinctly  circumscribed  from  the  surroundings.  The  tumor  was  characterized 
by  its  elastic  and  somewhat  fluctuating  consistence  as  a gummous  formation. 
On  the  clavicle  and  very  close  to  the  extremitas  acromialis , there  was  situated 
an  ulcer  two  inches  in  diameter , which  reached  to  the  non-necrosed  bone , 
exposing  two-thirds  of  an  inch  in  length  and  one  inch  in  breadth.  It  secreted 
a thin  pus , and  was  without  doubt  developed  from  the  ulcerative  destruction 
of  a gummy  knot.  Beneath  the  right  patella  there  was  a tumor , two  inches 
in  length  1 which  showed  a division  in  its  middle.  Its  consistence  was  still 
more  dense  than  the  above  described  gummata . 

We  immediately  began  the  injection  treatment  and  prescribed  for  the 
ulcer  on  the  clavicle,  irrigation  with  cold  water  by  means  of  the  atom- 
izer, as  already  pointed  out.  Under  this  treatment  the  tumor  under  the 
patella  was  the  first  to  subside,  so  that  after  the  use  of  lj  gr.  of  subli- 
mate it  was  entirely  gone.  The  remaining  required  rather  more  ener- 
getic doses. 

The  ulcer  on  the  clavicle  then  diminished  rapidly,  granulation  taking 
place,  so  that  the  patient,  after  using  4 gr.  altogether,  during  a stay  of 
five  weeks,  could  be  discharged  as  cured  November  18th,  1868. 


VII.  SYPHILITIC  AFFECTION  OF  THE  EYE. 

Syphilitic  affection  of  the  eye  is  an  important  disease. 
It  sometimes  appears  isochronal,  with  the  earliest  manifesta- 
tions of  syphilis  on  the  skin ; sometimes  it  accompanies  lues 


SYPHILITIC  AFFECTION  OF  THE  EYE. 


165 


in  its  tardy  appearance,  and  sometimes,  even,  the  disease  of 
the  iris  is  the  only  syphilitic  trace  in  the  relapse. 

The  really  syphilitic  iritis  is  very  difficult  to  discriminate. 
Generally  there  is  more  or  less  injection  of  the  conjunctival 
and  of  the  sub-conjunctival  vessels  which  surround  the 
cornea ; there  is  opacity  of  the  iris ; spotted  appearance  of 
the  same  produced  by  sub-serous  inflammatory  action ; ad- 
hesion of  the  pupils  to  the  crystalline  lens,  resulting  from 
exudation ; and  further,  there  are  the  subjective  symptoms, 
viz. : the  intolerance  of  light  and  deep-boring  pains  of  the 
orbita  shobting  along  the  course  of  the  supra-  and  infra- 
orbital nerves;  lachrymation  and  the  lessening  of  vision. 
Sometimes  there  are  small  tumors  of  the  size  of  a mustard- 
seed  up  to  the  size  of  a kernel  of  wheat,  of  a yellowish-red 
color.  These  are  generally  situated  in  the  middle  of  the 
tissue  of  the  iris,  sometimes  starting  from  the  central  border 
and  reaching  into  the  aqueous  humor.  These  tumors  have 
been  considered  by  some  authors  as  condylomes,  by  others 
as  gummata,  and  they  are  characteristic  of  the  syphilitic 
nature  of  the  iritis. 

The  plan  of  treatment  adopted  by  us  for  syphilitic  iritis, 
consisted  in  an  energetic  injection  of  sublimate  adapted  to 
the  case  in  question.  When  inflammation  was  very  intense ; 
exacerbations  of  fever  at  night ; penetrating  pain  not  only 
in  the  eye  but  also  in  the  supra-orbital  region ; increased 
lachrymation  with  great  intolerance  of  light;  when  there 
was  high  graded  opacity  of  the  iris ; reddish  appearances  of 
the  same  on  account  of  sub-serous  exudation,  so  that  the 
development  of  gummata  was  imminent,  &c. ; then  I began 
immediately  to  inject  ^ gr.  of  sublimate,  repeating  the 
injection,  according  to  the  intensity  of  the  iritis  and  the 
individuality  of  the  patient,  so  that  sometimes  already  on 


166 


SYPHILITIC  AFFECTION  OF  THE  EYE. 


the  first  day  § gr.,  and  in  one  case  even  1 gr.,  was  injected. 
The  result  was,  in  every  case,  very  good,  so  that  we  had 
relatively  a quick  and  complete  cure — in  lighter  cases 
already  after  1J  gr.,  in  harder  cases  after  5 or  6 gr. 

The  last-mentioned  dose  was  particularly  necessary  with 
three  patients,  in  whom  these  characteristics  in  the  iris  were 
formed. 

Besides  this  general  treatment,  we  used  locally  a weak 
solution  of  atropia.  Only  in  exceptional  cases  did  we  apply 
leeches  to  the  temporal  regions. 

It  is  remarkable  that  during  and  towards  the  end  of  a 
subcutaneous  treatment , used  for  something  quite  different , 
an  iritis  may  develop  itself  suddenly . This  reminds  us  of 
the  already  mentioned  appearance  of  suddenly  developed 
broad  condylomes  on  the  pharynx.  Such  cases  seem  not  to 
be  published  in  medical  literature,  and  I shall  relate  some 
of  them  by  and  by. 

Concerning  the  prevalence  of  the  iritis,  I have  a record 
of  twenty-five  cases  which  came  under  my  observation 
during  four  years.  In  eighteen  cases  which  were  carefully 
recorded  I find  the  following  complications  were  present : — 

Broad  condylomes  on  the  genitals  and  surroundings,  7 times. 
Superficial  erosions  at  the  same  place,  ...  6 u 

Uulcus  durum  on  the  penis, 1 11 

Condylomatous  ulcers  between  the  toes,  . 1 “ 

Maculous  syphiloid,  . . . . . . . 4 u 

Squamous  11  4 11 

Papuloso-vesicul.  syphiloid, 2 “ 

Pustulous  “ 2 “ 

Papuloso-pustulous  11  .....  3 “ 

Gummy  knots  on  the  scrotum,  ....  1 11 

Tophi  of  the  tibia, I 11 

In  three  patients  every  syphilitic  complication  was  wanting. 


SYPHILITIC  AFFECTION  OF  THE  EYE. 


167 


In  the  following  three  cases,  I give  the  first  as  an 
example  of  an  often-recurring  relapse  of  an  iritis  produced 
by  syphilis,  during  a period  of  twenty-four  years.  The  other 
two  cases  are  illustrations  where  condylomatous  iritis  was 
quickly  and  thoroughly  eradicated  by  injections  of  sub- 
limate. 

Case  55. — K.,  a merchant,  forty-six  years  old,  contracted  in  the  year 
1844  a hard  chancre,  and  he  underwent  a long  treatment,  the  details  of 
which  he  cannot  remember.  It  was  seemingly  healed,  but  he  had  an 
inflammation  of  the  eye  the  year  following,  which  was  examined  by 
several  oculists  and  pronounced  syphilitic.  In  spite  of  all  treatment 
the  iritis  made  its  appearance  every  year  until  the  year  1860,  i.  e.  fifteen 
times.  The  treatment  each  time  required  several  months.  The  last 
treatment  he  received  from  Dr.  Koblanck,  which  was  a mercurial  one, 
being  very  energetic  and  followed  by  a good  result,  since  then  there 
has  been  no  reappearance  of  iritis  for  seven  years.  In  October,  1868, 
the  patient  was  again  attacked,  and  sent  to  me  by  the  above-named 
gentleman. 

Patient  is  somewhat  weak  and  cachetic.  The  iritis  is  characterized  neither 
hy  subjective  nor  objective  syphilitic  symptoms , but  by  great  conjunctival  and 
sub -conjunctival  injection , paleness  of  the  iris,  and  dead  appearance  of  the 
pupil,  which  is  polygonally  stretched.  Vision  is  very  much  impaired,  and  at 
a distance  of  four  feet  it  is  nearly  impossible  for  the  patient  to  discern  anything. 
He  complains  of  a fixed  boring  pain  in  the  orbita  and  supra-orbital  region. 

I injected  J gr.  of  sublimate  in  the  back  and  2V  gr*  in  the  temporal 
region,  and  the  above  symptoms  quickly  disappeared.  The  further  use 
of  \ gr.  lessened  the  inflammation,  but  produced  toxical  symptoms,  as 
active  diarrhoea,  abdominal  pain,  nausea,  great  prostration,  &c.,  so  that 
we  had  to  suspend  injections  for  two  days.  We  used  after  this  f gr.  of 
sublimate  in  the  next  four  days,  which  caused  the  inflammation  to  sub- 
side so  rapidly,  that  the  patient  thought  himself  well  and  he  resumed 
his  work.  But  he  caught  cold,  and  the  iritis  got  worse.  On  that 
account  I began  again  the  injections,  giving  J gr.  doses,  and  in  the 
course  of  ten  days  I succeeded  in  overcoming  the  affection  of  the  eye. 
In  order  to  guard  against  further  relapses,  I injected  2 gr.  more  of  the 
sublimate.  But  whether  we  accomplished  a radical  cure  or  not  the 
future  will  show.  It  was  noticeable  that  the  patient,  in  spite  of  the 


168 


SYPHILITIC  AFFECTION  OF  THE  EYE. 


cold  and  stormy  weather,  attended  his  usual  avocation  without  danger 
and  risk. 

Case  56. — Louisa  H.,  22  years  old,  was  received  April  1,  1869,  into 
the  Charite,  and  showed  the  following  syphilitic  affections : condylo- 
matous  erosions  at  the  labia  majora  and  minora ; pigment-colored  ex- 
anthem  on  the  trunk,  and  iritis  condylomatosa  sinistra.  The  characteris- 
tic appearances  of  the  inflammation  of  the  retina  were  the  following: 
great  injection  of  the  conjunctival  and  sub -conjunctival  vessels , narrow  and 
stretched  pupil,  and  small  excrescences  of  angular  appearance  and  yellow- 
ish-brown color  in  the  region  of  the  pupil.  In  the  upper  segment  of  the  iris , 
we  can  see  a prolific  granulation  of  the  size  of  a kernel  of  wheat , which  rises 
button-like  over  the  tissue  of  the  iris. 

I used  J gr.  of  subl.  on  the  back  and  2V  gr.  in  the  temporal  region  by 
subcutaneous  injection,  and  I applied  atrophia  to  the  eye.  Examina- 
tion with  the  optlialmoscope  revealed  an  irregular  enlargement  of  the 
pupil.  There  were  especially  two  places  glued  together  on  the  inside 
border  of  the  pupil,  one  below  and  inside,  and  the  other  above  and  outside. 

In  consequence  of  these  adhesions  the  pupil  looked  like  a figure  8. 
On  the  whole  inner  border  of  the  iris  we  see  now  plainly  white-yellowish 
exudation-plaques  which  overlap  the  pupil,  in  an  angular  and  thread- 
like manner.  The  yellowish  prolific  granulation  on  the  outside  free 
borders  of  the  iris  is  plainly  visible  over  the  tissue  of  the  iris. 

In  the  following  three  days  we  again  used  daily  J gr.  of  subl.,  and 
thereby  produced  strong  salivation.  The  examination  made  April  6th, 
showed  that  the  condylomatous  prolific  granulations  on  the  iris  were 
reduced  to  half  their  former  size,  and  the  other  symptoms  were  much 
improved.  The  pains  in  the  orbita  and  the  intolerance  of  light,  had  all 
disappeared.  Vision  was  better.  Notwithstanding  the  existing  saliva- 
tion we  again  used  J gr.  of  sublimate.  The  consequence  of  this  forced 
injection  was  that  the  adhesions  were  completely  broken  up.  The  iris 
showed  a normal  lustre,  and  of  the  condylomes  no  trace  could  be 
found. 

To  completely  heal  this  case  of  condylomatous  iritis  1J  gr.  of  subli- 
mate were  sufficient. 

Case  57. — Henrietta  B.,  29  years  old,  of  weak  and  somewhat  ansemic 
appearance,  and  mother  of  a healthy  child  2J  years  old,  was  already 
treated  one  year  ago  in  our  hospital  for  a chancre,  receiving  only  local 


SYPHILITIC  AFFECTION  OF  THE  EYE. 


169 


medication.  Examination,  Dec.  19,  1868,  revealed  the  following  symp- 
toms : 

Purulent  vaginal  discharge,  urethritis,  a pigmento-papulo-vesiculo- 
pustulosum  exantliem,  especially  on  the  back  and  abdomen.  On  the 
fauces  is  erythema,  the  right  tonsil  being  tumefied  and  eroded.  There 
is  a double  condylomatous  iritis  and  keratitis  punctata  sinistra. 

About  both  eyes  there  is  great  conjunctival  and  pericorneal  injection.  Both  , 
cornea  are  much  clouded.  The  discolored  iris,  especially  of  the  right  eye , is 
adherent  to  the  crystaline  lens  at  several  points  posteriorly . The  polygonal 
pupil  has  the  shape  of  a vertical  oval  keyhole . From  the  border  of  the  pupil 
two  prolific  granulations  are  visible.  They  are  of  the  size  of  a pin-head,  with  a 
spongy  appearance,  reaching  into  the  aqueous  humor.  The  cornea  itself  is 
reddened  in  three  or  four  circumscribed  places.  With  the  iritis  of  the  left  eye 
we  also  see  prolific  condylomatous  granulations,  but  they  are  smaller  than  in 
the  right  eye,  and  seem  to  be  in  a state  of  development.  No  dilation  of 
the  pupil  follows  the  use  of  atropia. 

I prescribed  injections  of  sublimate  at  once,  using  the  first  day  J gr. 
and  the  following  three  days,  J gr.  daily.  After  the  use  of  J gr.,  the 
pupil  dilated  nearly  to  its  normal  size  ; the  right  but  slightly,  remaining 
yet  in  its  polygonal  shape.  After  using  1 gr.,  intolerance  of  light  and 
the  pericorneal  redness  disappeared  in  a great  measure.  The  aqueous 
humor  of  both  eyes  was  clearer,  and  the  condylomes  of  the  left  eye 
disappeared ; those  of  the  right  eye  were  much  subdued  in  appearance. 
The  conjunctival  redness  persisted,  however,  but  in  a lessened  degree. 
But  on  account  of  salivation,  the  injections  had  to  be  suspended.  After 
again  using  3 gr.  the  condylomatous  prolific  granulations  in  the  right 
eye  were  entirely  eradicated,  the  iris  assumed  its  normal  condition,  only, 
that  the  structure  was  a trifle  faded  in  appearance.  At  the  same  time 
the  other  symptoms  of  the  patient  disappeared,  and  she  was  dis- 
charged cured. 

The  following  three  cases  concern  patients  in  whom  iritis 
appeared,  either  during  an  anti-syphilitic  treatment,  or  after 
a long  duration  of  the  same. 

Case  58. — Augusta  W.,  27  years  old,  some  eight  months  advanced  in 
pregnancy,  mother  of  a healthy  boy  4 years  old,  was  received  into  the 
hospital  Oct.  22,  1866,  with  the  following  symptoms : condylomata  lata 
with  erosions  on  the  labia  majora  and  minora,  pudendi,  at  the  anus,  on 
15 


170 


SYPHILITIC  AFFECTION  OF  THE  EYE. 


the  plicae  fermorales,  and  on  the  tonsils  ; soft  nicer  on  the  thigh  ; ingui- 
nal, cervical  and  submaxillary  glands  tumefied. 

We  used  at  once  injection  of  sublimate,  but  the  affections  remained 
rather  obstinate,  so  that  about  5f  gr.  were  used  altogether.  Suddenly , 
after  being  seemingly  cured , an  iritis  appeared  in  the  right  eye , characterized 
by  great  conjunctival  and  sub-conjunctival  injection,  discoloration  of 
the  iris,  no  reaction  from  light,  great  intolerance  of  the  same,  lachry- 
mation  and  pain  in  the  orbita. 

I used  at  once  J gr.  doses  of  sublimate,  following  it  up  for  five  days, 
at  the  end  of  which  time  the  inflammation  of  the  eye  was  entirely 
gone.  Very  shortly  after  our  cure  the  patient  was  delivered  of  a 
healthy  and  robust  boy.  Soon  after  the  child  was  taken  with  a severe 
blenorrhoea  of  conjunctive,  coryza,  also  broad  condylomes  on  the  anus, 
and  a papulous  exanthem  on  different  parts  of  the  body.  It  died  in 
twenty-four  days. 

Case  59. — Fred.  S.,  day  laborer,  24  years  old,  received  November 
20,  into  the  Charite,  exhibited  the  following  affections  : Condylomata 
lata  and  erosions  on  the  nates;  acuminata  on  the  lamellae  of  the  pre- 
puce; condylomatous  ulcer  on  the  lips  ; papulous  exanthem,  more  espe- 
cially on  the  nape  of  the  neck. 

The  infection  took  place  three  months  ago  ; the  specific  symptoms 
showed  themselves  only  two  weeks  ago.  I prescribed  for  the  patient 
inunction,  with  gray  ointment,  4 grammes  daily  (64  gr).  The  broad 
papules  healed  after  the  10th  inunction.  The  ulcers  on  the  upper 
lip  began  to  cicatrize  after  the  16th  inunction.  But  after  a use  of  64 
grammes  (lj  oz.  nearly ) of  the  ointment , an  iritis  of  the  right  eye  was  devel- 
oped. The  appearances  were  so  characteristic  that  I presented  them  to 
my  clinical  students  as  clear  distinct  pictures  of  a syphilitic  iritis. 

I used  injections  of  sublimate,  which,  after  the  use  of  J gr.  during 
four  days,  brought  about  a complete  dissipation  of  the  inflammation  of 
the  retina,  the  other  syphilitic  complications  disappearing  at  the  same 
time. 


In  the  following  case  inflammation  of  the  iris  occurred  in 
spite  of  the  subcutaneous  injection  ; a papulous  exanthem 
developing  itself  on  the  abdomen,  neck  and  back  of  the 
patient. 


SYPHILITIC  SCROTAL  TUMORS. 


171 


Case  60. — L.  R.,  15  years  old,  was  received  into  our  hospital  on  the 
19th  of  February,  1865,  in  the  following  condition: 

There  were  broad  erosions  on  the  labia  minora,  and  plicae  femorales ; 
the  left  pudendum  was  tumefied.  For  these  affections  the  patient  had 
already  undergone  before  admittance  into  the  Charite  a very  severe  so- 
called,  u hunger  cure,”  of  about  five  weeks  duration. 

After  using  in  the  course  of  four  days  J gr.  of  sublimate  subcutane- 
ously, the  eroded  papillary  excrescences  on  the  pudendal  lips,  which, 
were  till  now  flat,  became  larger,  but  they  however  soon  diminished 
after  the  use  of  1 gr.  of  the  same.  The  conjunctival  and  sub-conjunc- 
tival vessels  of  the  right  eye  suddenly  became  injected  • the  iris  some- 
what discolored ; the  pupil  stretched  ; and  great  pain  was  felt  in  the 
orbita,  shooting  towards  the  supra  orbital  region.  At  every  trial  to 
fix  the  eye  on  an  object  great  lachrymation  ensued.  At  the  same  time 
with  this  iritis,  the  already  mentioned  characteristic  papules  appeared 
on  the  described  places. 

The  further  hypodermic  doses  of  J gr.  of  sublimate  caused  in  the 
weak  and  young  patient  a quite  severe  stomatitis,  on  which  account  we 
interrupted  the  treatment  for  about  one  week.  To  guard  against  re- 
lapses we  injected  about  \ gr.  more,  so  that  we  used  altogether  about 
If  gr.  with  the  patient.  The  patient  returned  twice  to  the  Charite 
after  the  lapse  of  fourteen  or  eighteen  months,  but  with  a most  minute 
examination,  we  could  find  no  sign  of  any  syphilitic  affection;  there 
being  nothing  but  blenorrhoeic  processes. 


VIII.  SYPHILITIC  SCROTAL  TUMORS. 

This  organ,  whose  parenchyma  is  very  rich  in  nerves  and 
capillaries,  is  quite  often  the  seat  of  gummous  processes. 
The  development  of  the  process  runs,  like  all  gummous 
affections,  a very  latent  course,  because  the  slow  formation 
of  the  tumors  produce  no  disturbances  in  the  sensibility. 
And  not  very  seldom  it  is  the  physician  who  first  points  out 
to  the  patient  this  affection.  And  this  is  the  more  strange, 
since  the  generality  of  men  watch,  as  is  well  known,  every 
functional  disturbance  of  the  testicle  with  the  eye  of  an 


172 


SYPHILITIC  SCROTAL  TUMORS. 


Argus.  And  I can  aver  that  in  my  practice,  in  all  cases 
where  I found  these  alterations  of  the  testicle,  the  patients 
did  not  consult  me  on  that  account,  hut  for  some  other 
syphilitic  process.  Therefore,  I could  get  but  few  data 
respecting  it  from  the  patients  themselves.  But  this  latent 
course  seems  to  me  a very  valuable  diagnostic  sign,  because 
all  other  pathological  processes  in  this  organ  produce  very 
much  more  pain  than  the  gummous,  and  hence  are  much 
sooner  noticed  by  the  patient — as,  for  instance,  the  tuber- 
culous and  carcinomatous  formations. 

Concerning  these  indolent  gummy  tumors,  I have  had 
occasion  to  observe  two  different  kinds.  The  one  form  is 
characterized  by  circumscribed,  semi-lunar,  hard  knots  of 
the  size  of  a pea  or  hazelnut,  reaching  above  the  paren- 
chyma of  the  scrotum.  This  formation  is  generally  the 
first  state  of  the  syphilitic  sarcocele,  where  the  scrotum  has 
already  more  or  less  enlargement.  This  is  quite  natural, 
considering  the  development  of  the  gummata  of  the  scrotum, 
which  arise  from  the  albuginea,  in  which  the  testicle  is 
wholly  wrapped,  and  from  the  septa-testis,  they  being  already 
hyperplastically  degenerated  before  becoming  specific  neo- 
plasm. 

In  the  second  form  of  the  gummous  sarcocele  on  the 
largely  hypertrophied  testicle,  a few  circumscribed  tumors 
of  hard  resistance  were  found ; hut  generally  the  whole 
testicle  was  changed  into  a knotty  mass. 

As  to  the  therapeutics  for  this  orchitis  gummosa,  it  might 
be  well  to  preface  the  treatment  with  the  internal  adminis- 
tration of  iodide  of  potassium ; but  with  a long  resistance, 
and  in  relapses,  I think  it  justifiable  to  use  the  injection 
treatment.  In  the  cases  observed  by  me,  we  had  generally 
to  treat  very  rebellious  and  obstinate  affections,  and  some- 


SYPHILITIC  SCROTAL  TUMORS. 


173 


times  very  long-standing  relapses.  On  this  account  I was 
obliged  to  use  greater  doses,  and  repeat  them  quite  often. 
But,  after  all,  in  some  cases  I failed  entirely  to  effect  a 
cure.  The  tumors  were  considerably  swollen,  but  once  in  a 
while  there  were  on  the  testicle  small  elevations,  having  a 
hard  resistance ; and  here  I used  Fricke’s  method  of  band- 
aging with  adhesive  straps,  which  sometimes  had  a good 
result. 

Of  my  numerous  cases,  I shall  give  the  following  marked 
case,  with  a view  to  show,  on  the  one  hand,  the  good  effects 
of  the  subcutaneous  method ; and  further,  that  in  a syphilitic 
patient,  after  a lapse  of  ten  years,  a relapse  may  occur,  and 
too  in  a very  dangerous  form,  which  is  attributed  by  anti- 
mercurialists  to  the  administration  of  quicksilver ; but  here 
the  patient  himself  was  a follower  of  Baerensprung,  and 
never  had  used,  for  his  first  syphilitic  affection,  nor  for  his 
secondary  symptoms,  a grain  of  mercury. 

Case  61. — St.,  a merchant;  from  a healthy  family,  and  of  a robust 
constitution  ; always  healthy ; was,  in  the  year  1856,  syphilitically  in- 
fected. His  physician  diagnosed  a soft  chancre  ; but  a year  after, 
symptoms  of  constitutional  syphilis  made  their  appearance,  showing 
the  error  committed.  Professor  Bserensprung  was  then,  consulted,  and 
that  gentleman,  just  having  begun  his  metamorphosis  as  an  anti-mercu- 
rialist,  prescribed  for  him  for  a length  of  time,  with  seemingly  good  re- 
sults, the  decoctum  Zittmanni,  and  to  be  sure  of  its  efficacy,  he  ordered 
iodide  of  potassium  to  be  used  for  some  time  also.  The  patient 
returned  the  next  winter  from  a voyage  to  Norway,  where  he  made  the 
acquaintance  of  Professor  Boeck,  and  delivered  this  gentleman’s  known 
works  to  Yirchow  and  Bserensprung.  The  latter  assured  him,  after 
repeated  examination,  that  he  was  sound,  not  only  for  the  present,  but 
healed  from  the  effects  of  syphilis  for  the  future,  as  the  patient  himself 
told  me  particularly , because,  according  to  Baerensprung’s  opinion,  the 
time  11  necessary  for  a relapse”  was  already  overpassed,  since  the  pa- 
tient had  lived  during  a cold  winter  in  the  North.  Suspicious  erosions 
on  the  penis,  probably  of  a condylomatous  nature,  were  treated  only 

15* 


174 


SYPHILITIC  SCROTAL  TUMORS. 


with  nitrate  of  silver,  locally — together  with  iodide  of  potassium  inter- 
nally. This  cure  lasted  for  a few  years ; but,  as  we  shall  see,  a relapse 
proved  the  cure  to  be  only  temporary.  The  patient  suffered  for  quite  a 
time  with  an  obstinate  cold  in  the  head,  as  he  thought ; but  in  the 
year  1867  the  quantity  and  quality  of  the  secretion  were  so  augmented 
that  great  masses  of  mucus  and  pus,  intermingled  with  blood,  were 
secreted.  The  nostrils  became  stenosed,  and  the  voice  had  that  pecu- 
liar nasal  twang.  The  snoring  during  sleep  was  so  peculiar  and  loud 
that  it  could  be  heard  at  quite  a distance.  “ My  whole  nervous  sys- 
tem,” added  the  patient,  “was  by  that  heavy  cold  and  an  awful  head- 
ache so  affected,  and  I was  so  weak,  that  I hardly  could  keep  awake.” 

I examined  the  patient  in  June,  1868,  and  found  the  following  status 
prsesens  : On  the  velum  and  palate-roof  shallow , not  deep-going , ulcerations  ; 
and  on  the  epiglottis  I perceived  an  ulcer  of  the  size  of  a small  penny . The 
cavity  of  the  nose  was  filled  with  a yellow , dirty , thick-flowing  secretion  from 
ulcers  reaching  far  into  the  swollen  mucous  membrane . The  face  of  the  pa- 
tient appeared  bloated , especially  around  the  eye  and  nose.  In  a further  ex- 
amination, I found,  to  the  surprise  of  the  patient , verg  large  gummous  knots 
on  both  testicles , of  the  size  of  hazelnuts , which  had  so  changed  the  right  testicle 
into  a bulky , elevated  mass  that  it  resembled  a fist  in  shape . 

I began  the  subcutaneous  injection  at  once,  and  after  a lapse  of  eight 
days,  there  was  a visible  change  for  the  better  in  the  affection  of  the 
mucous  membrane  of  the  nose.  In  three  weeks  the  same  was  again  in 
its  normal  state. 

The  knots  upon  the  testicle  were  more  unyielding.  Even  after  the 
lapse  of  two  and  a half  months,  after  using  5J  grs.  of  sublimate  subcu- 
taneously, small  remnants  of  the  tumors  were  yet  present.  The  pa- 
tient was  much  delighted  with  the  result,  and  broke  off  the  treatment ; 
but  after  seven  weeks,  the  right  testicle  was  again  tumefied,  several 
of  the  elevations  being  felt  much  less  plainly  than  before.  The  secre- 
tion of  the  nose  was  somewhat  augmented  and  tenacious,  being  occa- 
sionally streaked  with  blood. 

I prescribed  now  iodide  of  potassium,  and  for  the  nose  I used  Weber’s 
nasal  douche,  with  chamomile  decoction.  At  the  same  time,  I band- 
aged the  scrotum,  lege  artis , with  straps  of  emplastrum  hydragyrum.  But 
all  this  was  without  avail,  and  I was  obliged  to  use  again  injections  of 
sublimate.  And  I had  the  satisfaction  to  notice,  after  the  use  of  5 grs. 
of  sublimate,  that  the  testicle  was  reduced  to  its  normal  size,  and  that 
also  the  last  remnants  of  the  affection  in  the  vicinity  of  the  mouth  had 
disappeared.  Up  to  the  present  time  (June,  1869),  no  relapse  has  yet 
oecurred. 


SYPHILITIC  AFFECTIONS  OF  THE  BONES. 


175 


IX.  SYPHILITIC  AFFECTIONS  OF  THE  BONES. 

The  affection  of  the  bones  is  the  most  latent  and  obsti- 
nate effects  of  syphilis.  In  no  other  system  of  the  human 
organism  does  lues,  at  the  same  time,  so  often  show  its 
polymorphous  character  as  in  the  osseous. 

These  processes  generally  begin  with  irritative  diseases  of 
the  periosteum,  but  gradually  rise,  by  hyperplasia,  into  pro- 
lific granulations.  They  show  their  culmination  by  forma- 
tions of  elastic  gummous  tumors,  which  change  either  into 
real  hyperostosis,  or  go  into  a metamorphosis,  finally  re- 
sulting in  caries  and  necrosis,  thus  displaying  their  malign 
nature. 

The  first  commencement  of  syphilis  in  the  bones  consists 
in  a swelling  of  the  periosteum,  which  can  hardly  be  de- 
tected by  an  examination,  and  which,  according  to  high 
authorities,  does  not  form  a flat  swelling,  but  “is  elastic 
under  pressure/ ’ It  is  commonly  concomitant  with  super- 
ficial affections  of  the  skin  and  mucous  membrane,  and  is 
accompanied  with  lancinating  pain.  They  are  distinguished 
in  a characteristic  manner  from  the  rheumatic  pains  caused 
by  an  eruptive  fever,  which  pains  are  sufficiently  marked  by 
their  fixed  and  circumscribed  seat,  and  by  the  sensitiveness 
of  the  fibrous  periosteum  to  every  pressure. 

Later,  there  are  more  palpable  changes  of  the  bone,  especi- 
ally in  those  flat,  unossified  intumescences  of  an  elastic  con- 
sistency. They  occur  on  the  tubera  frontalia,  diaphysis  of 
the  tibia,  and  frequently  on  the  sternum,  clavicle  ribs,  &c., 
and  in  the  latter  places  are  very  often  seated  near  the  articu- 
lations. Quite  frequently  I have  found  the  disease  in  ques- 
tion having  its  seat  on  the  processus  mastoideus.  Here  I 


176 


SYPHILITIC  AFFECTIONS  OF  THE  BONES. 


would  discover  just  behind  the  ear — sometimes  already  after 
the  expiration  of  three  or  four  months,  and  sometimes  still 
later — flat  swellings  painful  to  the  touch ; even  swellings  of 
the  size  and  form  of  an  almond,  which  could  very  easily 
be  confounded  with  swelled  lymphatics.  In  some  instances 
they  would  be  sensitive  to  only  a small  extent  and  were 
hardly  noticed  by  the  patient;  in  other  cases  they  had 
spontaneously  more  or  less  painfulness. 

In  the  later  course  we  see  the  periosteal  gummy  tumor, 
with  simultaneous  action  of  the  upper  layer  of  the  bone,  take 
on  an  ossified  condition,  changing  into  plano-convex  hyper- 
ostosis or  exostosis  and  osteophytes. 

All  these  formations  are  characterized  by  a boring  pain, 
which  prevents  sleep,  and  consequently  affects  the  nutritive 
system  very  much. 

The  changing  of  the  periosteal  gummous  tumors  into 
ulcerative  metamorphosis,  i.  e.,  the  development  of  an  ulcera- 
tive periostitis — I never  noticed  in  my  patients  because  those 
processes  were  already  healed  by  my  subcutaneous  injection 
treatment.  In  some  cases  I have  had  occasion  to  observe 
caries  and  necrosis  which  existed  with  the  patients  when 
they  were  brought  into  our  wards,  and  I thought  it  justifiable 
to  regard  suppurative  periostitis  as  the  exciting  cause,  be- 
cause the  initial  affections  on  the  bones  were  yet  visible. 

The  therapeutics  of  the  syphilitic  diseases  of  the  bones  has 
the  same  indication  as  in  the  already  described  gummous 
processes.  The  same  principles  exist  here,  as  there,  to  dis- 
tinguish, for  iodide  of  potassium  or  injections  of  sublimate. 
The  effect  of  the  latter  depends  on  the  state  of  the  bone 
affection.  In  the  first  described  state,  the  lancinating  pain, 
and  the  periosteal  tumefaction  disappear  after  small  doses  of 
sublimate  rather  quickly.  The  characteristic  elastic  tumors 


SYPHILITIC  AFFECTIONS  OF  THE  BONES. 


177 


require  larger  doses.  They  are  absorbed  in  a short  time 
without  a depression  of  bone  remaining  on  the  affected  places. 
And  it  seems  as  if  the  apparently  dead  and  partially  broken 
down  tissue  is  reducible  by  a fatty  metamorphosis,  and  can, 
therefore,  be  absorbed.  In  already  new  formations,  from 
the  really  sclerotic  bone  development,  the  results  of  the  in- 
jection are  not  so  favorable.  Even  in  long  standing  cases 
where  different  treatments  failed,  and  where  great  meta- 
morphosis of  form  and  texture  had  already  taken  place,  I 
succeeded  in  effecting  a complete  disappearance  of  the  already 
mentioned  pain  in  the  bones. 

In  quite  a number  of  cases,  a decided  lessening  of  the 
volume  of  the  tumors  took  place  on  account  of  resolution  of 
the  remaining  gummous  formation,  but  the  hyperostosis  did 
not  diminish,  which  was  produced  by  hypertrophy  of  the  ex- 
terior of  the  bone,  and  the  chalky  process  which  the  peri- 
osteum underwent.  To  restore  such  a bone  to  its  integrity 
could  not  be  expected  from  any  treatment. 

Concerning  the  ulcerative  process  of  the  bone,  produced 
either  by  periostitis  or  osteitis,  or  resulting  from  the  ulcera- 
tive process  of  the  soft  parts  reaching  into  the  bone,  the 
same  rule  holds  good  that  has  been  laid  down  respecting 
ulcers  on  the  skin,  reaching  down  to  the  bones.  They  need 
a special  surgical  interference  to  remove  the  sequestra,  even 
if  the  syphilitic  dyscrasia  has  been  eradicated  by  sublimate 
injections. 

We  have  already  published  cases  with  affections  of  the 
bones,  and  in  the  following  cases  I take  those  showing  the 
different  periods  of  the  disease,  beginning  with  the  first  state. 

Case  62. — Julius  W.,  blacksmith,  twenty-six  years  old,  was  received 
into  the  Charite  wards  February  22,  1867.  Eight  weeks  previously,  he 


178 


SYPHILITIC  AFFECTIONS  OF  THE  BONES. 


had  gonorrhoea,  two  weeks  afterwards  a hard  ulcer  on  the  glans,  which 
caused,  in  about  eight  days,  phymosis. 

Patient  is  of  fair  constitution  and  muscle.  His  chief  complaints  are 
shooting  pains  in  the  region  of  the  right  musculus  pectoralis . Examination 
revealed  that  the  seventh  rib , near  its  junction  with  the  sternum  is  but  little 
swollen , yet  very  painful  to  the  touch.  Of  further  syphilitic  processes,  we  find 
glandular  ulcers  ; induration  of  the  lamellae  of  the  prepuce ; the  right 
tonsil  swollen  and  maculous  exanthema.  The  inguinal  glands  were 
principally  swollen. 

We  injected  for  the  first  three  days  T7g  gr.  doses  of  sublimate.  Already 
after  the  third  injection,  the  ulcers  on  the  glands  were  healed,  and  the 
phymosis  gone.  We  reduced  the  doses  one-half  to  -fo  gr.  After  the 
seventh  injection,  the  induration  on  the  prepuce  was  nearly  gone,  and 
the  exanthem  entirely  vanished.  After  the  ninth  injection  (3  gr.  having 
been  used)  the  periostitis  on  the  seventh  rib  had  also  subsided. 

The  patient  was  discharged  cured,  April  12,  1867. 

It  was  remarkable  that  after  the  second  and  fifth  injections,  the  al- 
ready described  symptoms  of  intoxication  appeared  under  the  form  of  a 
gastritis  with  colic  pains,  bloody  diarrhoea,  which  passed  away  without 
any  interference  by  pausing  for  a few  days  with  the  subcutaneous  medi- 
cation. 

Case  63. — Johanna  M.,  twenty-three  years  old,  was  received  January 
14,  1867.  The  patient  was  already  in  our  syphilitic  wards  four  years 
ago,  suffering  from  broad  condylomes  and  condylomatous  angina,  be- 
sides she  had  a squamous  exanthem, ‘ and  was  treated  with  a five  weeks 
sarsaparilla  sweat-cure.  At  present  she  suffers  from  lupus  syphiliticus 
and  rupia.  On  the  shoulder,  hip,  thigh  and  right  tibia,  there  are  places 
partially  round  and  oval,  and  of  a brown  pigment  color,  which  are  ele- 
vated somewhat  above  the  skin,  showing  some  infiltration.  With  some 
the  centres  are  deepened,  the  periphery  being  covered  with  a brownish 
white,  and  somewhat  leaf-like  crust,  by  the  removal  of  which  bleeding 
ensues.  On  the  moist  places  the  developments  could  be  traced  to 
efflorescences.  Besides,  here  and  there  over  the  body  there  were  several 
cicatrices  of  the  size  of  a penny,  which  resembled  brown  circles  with 
lighter  centres.  The  right  tibia  was  swollen  to  a great  extent , also  the  left 
metacarpal  bones.  Both  places  were  very  painful  to  the  touch.  At  the  same 
time  the  patient  complained  of  extreme  boring  pains  during  the  night  at  the 
same  localities. 

The  treatment  consisted  of  sublimate  injections,  with  the  simultaneous 


SYPHILITIC  AFFECTIONS  OF  THE  BONES. 


179 


use  of  very  small  doses  of  iodide  of  potassium.  After  the  sixth  injection 
the  lupous  places  were  covered  only  with  small  squamae,  soft  to  the  touch. 
On  the  extremities  there  yet  were  some  infiltrations,  and  a large  crust 
in  the  vicinity  of  the  left  knee.  After  the  tenth  injection  (1J  gr.)  the 
lupous  ulcers  were  entirely  healed,  the  pigment  in  the  centre  of  the 
respective  places  pale.  On  the  left  lower  extremity  there  was  a thin 
rupial  crust,  beneath  the  same  were  prolific  granulations  of  the  corium 
in  the  surrounding  smaller  crusts.  The  swelling  of  the  tibia  and  meta- 
carpal bones  was  lessened  and  they  were  painless.  After  the  eleventh 
injection,  the  former  infiltrations  vanished,  and  the  swelling  on  the 
tibia  was  very  much  less.  After  the  twelfth  injection  (l£  gr.)  the  tume- 
faction had  also  disappeared. 

The  patient  was  discharged,  cured,  February  23,  1867. 

In  the  following  patients  there  were  greater  affections  of 
the  bone,  which  remained  healed  after  a treatment  with  the 
subcutaneous  injection,  notwithstanding  several  relapses  of 
rupia,  which  probably  were  occasioned  by  the  voluntary  in- 
terruption of  the  treatment  by  the  patient. 

Case  64. — William  R.,  baker,  thirty-five  years  old,  was  received  into 
the  Charite  Hospital  November  19,  1865.  His  former  history  showed 
that  the  patient  had,  two  years  ago,  ulcers  on  the  frenulum,  for  which 
he  used  some  mercurial  pills.  About  seven  weeks  ago,  he  contracted 
again  a new  ulcer  on  the  same  place,  which  has  been  accompanied  by 
an  eruption  on  the  skin.  Again  mercurial  pills  were  used  which  caused 
salivation.  Status  prsesens : An  induration  near  the  destroyed  frenulum ; 
eroded  lata  near  the  pharyngeal  palate  roof;  a papulous  squamous  ex- 
anthem over  the  whole  body  entirely,  more  or  less  of  them  having  scab 
formations  ; tophi  on  the  forehead  and  tibia  ; boneache  (dolores  osteocopi), 
and  slight  tumefaction  of  the  inguinal,  cervical,  submaxillary  and 
cubital  glands. 

The  patient  received  twenty-four  injections  during  seventeen  days, 
amounting  to  3 gr.  of  sublimate.  After  using  2 gr.  the  elevation  on  the 
frontal  bone,  and  the  night  pains  were  already  gone,  but  the  exanthem 
was  not  quite  healed.  The  patient,  nevertheless,  left  the  hospital  by 
his  own  choice,  but  returned  within  a month.  Examination  then  re- 
vealed, that  of  the  former  affections,  only  the  papulo-squamous  ex- 


180 


VISCERAL-SYPHILIS. 


anthem  on  the  face,  neck  and  on  the  extremities,  were  yet  present,  and 
that  also  the  above  mentioned  glands  were  still  swollen.  I prescribed 
a sarsaparilla  sweat-cure,  but  being  without  result  after  a six  weeks’ 
use,  injections  wrere  again  instituted,  which  caused  a partial  recovery, 
after  the  use  of  If  gr.  of  sublimate,  but  no  complete  healing. 

In  spite  of  our  warning,  the  patient  left  again,  but  returned  once  more 
to  the  hospital  after  three  and  a half  months.  Besides  superficial  ero- 
sions of  the  internal  lamellae  of  the  prepuce,  we  found  only  several 
papulous  efflorescences  of  the  size  of  a pea  on  the  forehead,  neck  and 
right  upper  arm  which  were  quite  soft  to  the  touch.  We  treated  him 
locally  only,  and  discharged  him  soon  afterwards. 

He  sought  relief  again  in  our  wards  two  and  a half  years  afterwards. 
He  told  us  that  up  to  July,  1868,  he  felt  quite  well,  having  suffered  much 
affliction  and  perplexity  in  obtaining  a livelihood.  He  was  obliged  to 
go  for  quite  a time  without  any  animal  food.  At  this  date  horny  ex- 
crescences had  developed  themselves  on  the  scalp,  which  soon  ulcerated. 

The  patient  was  very  much  emaciated  and  cachectic.  We  found  by 
examining,  that  the  head,  as  well  as  the  back  and  right  arm,  was  covered 
with  rupia  crusts  of  the  size  of  a penny.  On  the  uvula  and  epiglottis 
there  were  ulcerations  as  large  as  a pea. 

We  first  prescribed  a good  strengthening  diet  with  wine  and  beer,  and 
after  a fortnight,  we  commenced  our  injection  treatment,  healing  all  the 
ulcers  and  eruptions  completely  with  4 gr.  sublimate.  But  to  guard 
against  relapses,  we  used  2 gr.  more  of  sublimate,  and  had  the  satis- 
faction to  discharge  the  patient  completely  cured  and  strengthened. 
Quite  recently  he  sent  me  a letter  telling  me  of  his  complete  health. 


X.  VISCERAL-SYPHILIS. 

In  consequence  of  the  high  interest  which  latterly  is  cen- 
tred voluntarily  upon  the  teachings  on  syphilis  of  the  internal 
organs,  I regret  very  much  that  I have  but  a few  cases 
wherein  I have  made  any  observations.  These  cases  of  vis- 
ceral syphilis  do  not  occur  as  often  as  the  specific  diseases  of 
the  external  and  more  superficially  situated  regions  of  the 
body,  but  after  all  they  are  not  quite  so  rare  as  generally 
supposed.  Very  many  of  the  cases  are  wrongly  diagnosed, 


SYPHILITIC  DISEASES  OF  THE  LIVER. 


181 


and  therefore  but  sparsely  seen  in  our  syphilitic  wards  of 
the  Charity. 

That  the  internal  organs  are  quite  frequently  syphilitically 
affected,  is  well  authenticated  by  careful  post-mortem  exami- 
nations, especially  in  pathological  anatomical  institutions. 
Syphilitic  diseases  have  been  observed  very  frequently, 
particularly  in  the  brain,  liver,  kidneys,  and  even  in  the 
lung  itself,  and  we  are  compelled  to  feel  thankful  to  Virchow 
for  this  careful  dissection  and  examination,  which  has  made 
such  researches  famous  throughout  the  world. 

The  difficulty  of  diagnosing  visceral  syphilis,  intra  vitam , 
is  very  great,  arising  out  of  the  long  interval  of  years  be- 
tween the  infection  and  the  outbreak  of  the  disease  inter- 
nally, and  from  the  deficiency  of  a specific  group  of  symptoms 
which  distinguish  internal  syphilitic  formations  sharply  from 
the  syphilis  vulgaris. 

A.  SYPHILITIC  DISEASES  OF  THE  LIVER. 

The  liver  is  generally  the  chief  organ  affected  in  the 
greatest  number  of  cases  of  visceral  syphilis. 

Although  immediately  after  the  appearance  of  syphilis  in 
the  fourteenth  century,  the  liver  was  looked  upon  as  the  or- 
gan primarily  attacked  by  the  syphilitic  contagion,  seemingly 
poisoning  the  circulation,  it  is  only  recently  that  a sound 
pathology  of  syphilitic  disease  has  been  established.  It  is  to 
be  regretted  that  clinical  observation  has  not  kept  pace,  in 
this  respect,  with  pathological  anatomy. 

Although  pathology  has  pointed  out  the  more  or  less 
characteristic  symptoms  of  a syphilitic  perihepatitis  of  a 
simple  syphilitic  interstitial,  gummous  and  amyloid  hepatitis, 
we  do  not  possess  a single  pathognomonic  sign  by  which  we 
16 


182 


SYPHILITIC  DISEASES  OF  THE  LIVER. 


can  distinguish,  during  life,  these  diseases,  caused  by  syphilis 
in  the  liver,  from  diseases  of  the  same  organ,  from  other  cases. 
Neither  the  subjective  nor  objective  symptoms,  detected  by 
palpitation,  percussion,  &c.,  nor  even  microscopic  examina- 
tion, nor  chemical  analysis  of  the  secretions  and  excretions 
themselves,  can  furnish  us  evidence  for  a diagnosis.  Diagnosis 
will  always  have  to  be  based  on  the  fact  of  a syphilitic  in- 
fection, together  with  the  simultaneous  symptoms  of  perhaps 
a yet  existing  syphilis,  and  the  exclusion  of  other  sufficient 
causes.  Another  help  for  diagnosis  is  generally  and  mostly 
overlooked,  I mean  the  therapeutic  experiment.  We  abstain 
from  a mercurial  cure  on  account  of  the  cachectic  state  of 
the  patient,  which  we  regard  as  a contra-indication  for  this 
venenum  frigidum.  A good  treatment  instituted,  would,  in 
many  cases,  not  effect  a radical  cure,  hut  would  prolonglife. 
The  subcutaneous  treatment  with  the  sublimate  would  not 
restore  the  parenchyma  to  a normal  structure,  which  had 
been  vitiated  by  an  amyloid  process,  nor  the  liver-acini  which, 
by  the  retraction  of  the  tightened  tissue  are  atrophied,  but 
used  at  the  proper  time,  the  inflammatory  process  which  is 
more  or  less  connected  with  the  shrinking,  would  be  stayed, 
and  thus  the  hyperplasia,  the  prolific  growth  of  tissue, 
would  be  anticipated.  But  how  seldom  with  such  diseases 
a suitable  antisyphilitic  cure  is  instituted,  is  shown  by  a 
careful  perusal  of  our  medical  literature.  The  cases  are  not 
very  rare  where  only  on  the  dissecting  table  the  right  diag- 
nosis is  made. 

We  grant  that  in  recent  times  a certain  progress  has  been 
made  in  the  diagnosis  of  syphilitic  cirrhosis,  but  we  cannot 
say  the  same  of  that  affection  which,  according  to  my  obser- 
vations, often  has  more  of  a specific  character  than  we  sup- 
pose, I mean  the  syphilitic  icterus. 


SYPHILITIC  DISEASES  OF  THE  LIVER. 


183 


There  is  certainly  not  a sure  diagnostic  sign  between 
icterus  and  syphilis  of  the  liver,  and  in  our  cases  we  could 
detect  none,  because  clinical  observations,  as  has  already 
been  said,  have  not  as  yet  established  them. 

But  the  following  points  seem  to  us  of  more  or  less  im- 
portance in  designating  an  icterus  a syphilitic  one,  viz. : 

1.  The  relatively  often  appearance  of  icterus  with  syphilis. 

In  the  last  four  years  I have  observed  nineteen  cases  of 

icterus.  Among  these  sixteen  were  syphilitic,  and  the  other 
three  were  not  affected  with  secondary  syphilis.  The  number 
of  this  latter  class  is  generally,  in  my  wards,  twice  as  large 
as  the  number  who  have  constitutional  syphilis. 

2.  The  coincidence  of  the  icterus  with  the  syphilitic  affections 
of  the  skin  and  mucous  membrane . 

In  fourteen  syphilitics,  the  icterus  was  accompanied 

9 times  with  broad  condylomes  on  the  sexual  parts  and  surroundings. 


hard  ulcers  on  the  same. 

ulceratively  destroyed  condylomatous  granulations  on 
the  pharynx, 
maculous  exanthem, 
maculous  squamous  exanthem, 
maculous  papulous  exanthem, 
papulous  exanthem, 
pustulous  exanthem. 


3.  The  simultaneous  swelling  of  the  lymphatics , which,  in 
all  cases,  is  more  or  less  characteristic. 

4.  The  therapeutical  result  of  the  subcutaneous  injection . 
Of  sixteen  syphilitics  suffering  with  icterus 

4 patients  were  treated  with  the  sarsaparilla  sweat-cure. 

12  “ 11  11  sublimate  injection. 

It  was  noticeable  that  with  the  first  class  the  healing  pro- 
cess of  the  icterus  was  slower,  and  accompanied  with  great 


184 


SYPHILITIC  DISEASES  OF  THE  LIVER. 


prostration,  nausea,  vomiting,  vertigo,  &c.  But  on  the  con- 
trary the  icterus  run  a quicker  course  in  those  persons 
treated  with  the  injection,  and  no  untoward  symptoms  were 
noticed.  I never  observed  any  toxicological  effect  of  the  bile 
on  the  blood  or  nervous  system.  No  patient  had  convulsions 
or  delirium.  All  improved  quickly;  the  appetite  reap- 
peared, and  the  strength  in  due  course  of  time ; the  painful 
symptoms  of  the  disease,  as  unquiet  sleep,  headache,  flatu- 
lency, prurigo  and  constipation,  were  soon  gone. 

I further  made  this  observation,  which  is  worthy  of  remark, 
and  may  lead  to  additional  investigation : as  is  well  known, 
patients  with  icterus  proper,  emaciate  quickly,  but  our  pa- 
tients, on  the  contrary,  had  not  a rapid  loss  of  strength  or 
flesh.  One  could  judge  of  the  case  in  this  respect  by  fre- 
quently weighing  the  patient.  My  patients  kept  their  strength 
and  flesh,  in  spite  of  my  giving  relatively  large  doses  of  sub- 
limate subcutaneously,  and  further  on  account  of  our  pecu- 
liar system  in  the  hospital,  a dietetic  regime  could  not  be 
very  well  executed. 

Case  65. — Thresa  B.,  seventeen  years  old,  of  a robust  constitution, 
was  received  into  the  Charite  wards  February  17,  1867,  and  showed  the 
following  symptoms  : There  were  ulcerated  lata  at  the  labia  majora,  on 
the  tonsils  and  mammas ; also  squamous  exanthem  near  the  upper  ex- 
tremities. On  the  chin,  cheeks,  upper  lips  and  on  the  sides  of  the  nos- 
trils, we  saw  remarkable  fine  drawings  (squamae  gyratae)  of  greater  or 
smaller  circles,  which  reminded  one  of  herpes  circinatus  and  gyratus. 
A close  examination  revealed  small  epidermic  scales,  seated  on  the  sur- 
face, which  was  swollen  into  minimum  papules.  The  inguinal,  cervical 
and  cubital  glands  were  enlarged.  The  color  of  the  skin  and  conjunctiva 
is  yellow  with  a shade  of  brown.  The  hue  of  the  visible  mucous  membrane , 
especially  on  the  hard  and  soft  palate , is  a dirty  yellow.  Laryngoscopic 
examination  shoived  the  vocal  cords  to  be  discolored  in  the  same  manner. 
Tongue  coated ; the  dullness  of  the  liver , commencing  at  the  sixth  rib , is  not 
very  intense , and  overreaches  in  the  parasternal  and  mammillar  line , the  lower 


SYPHILITIC  DISEASES  OF  THE  LIVER. 


185 


border  of  the  ribs , a little  more  than  usual.  The  region  of  the  liver  is  some- 
what painful  under  touch , also  the  epigastrium  which  is  a little  swollen.  The 
dullness  over  the  spleen  is  not  enlarged.  Percussion  on  the  abdomen  is 
loud,  deep  and  symptomatic.  Only  in  the  left  iliac  region  was  the  sound 
less  prolonged  and  fuller.  The  whole  abdomen  is  somewhat  enlarged. 

The  patient  complains  of  general  malaise,  loss  of  appetite,  bad  taste, 
increased  thirst,  restless  sleep,  and  a feeling  of  heaviness  in  the  region 
of  the  stomach  and  right  hypochondrium.  The  itching  is  not  very  sig- 
nificant. Since  two  days  there  has  been  no  stools.  There  is  voided 
daily  of  urine  sixteen  hundred  cubic  centimeter  in  quantity,  of  a specific 
gravity  of  ten  hundred  and  twelve,  of  a very  yellow  color ; a chemical 
analysis  revealing  much  biliary  coloring  matter  in  the  same. 

We  first  prescribed  an  infusion  of  rhubarb,  and  as  the  subjective  and 
objective  symptoms  of  the  icterus  did  not  disappear,  I began  to  suspect 
the  disease  to  be  syphilitic  icterus,  and  therefore  commenced  the  sub- 
cutaneous injections  of  sublimate.  The  first  three  days  we  injected 
doses  of  gr.  each,  and  the  following  three  days  doses  of  J gr.  each. 
The  treatment  had  a good  result.  After  the  use  of  lj  gr.  the  skin  lost 
its  brown  color,  and  after  the  further  use  of  the  same  quantity,  it  as- 
sumed its  natural  appearance.  The  patient  gained  right  along,  so  that 
with  2 gr.  used,  she  felt  quite  well.  After  using  still  another  1J  gr.  of 
sublimate,  the  biliary  coloring  matter  could  not  be  anywhere  more  de- 
tected, and  she  was  discharged  after  three  weeks,  cured. 

Case  66. — Mary  H.,  twenty-one  years  old,  of  a gracile  habitus,  and  a 
weakly  constitution,  always  healthy,  says  that  about  two  weeks  before 
her  admission  into  the  Charite,  she  suffered  from  indigestion. 

On  December  2,  1868,  the  following  was  revealed  by  examination : 
condylomata  lata  at  the  labia  majora  which  is  tumefied  ; soft  ulcer  on 
the  posterior  commissure  of  the  vagina ; acuminata  in  the  same  place  ; 
an  ulcerated  anal  fissure  ; elevated  lata  near  the  tonsils  and  the  posterior 
roof  of  the  pharynx , and  icterus. 

An  accurate  examination  failed  to  reveal  any  demonstrable  physical 
changes  of  the  liver  or  abdominal  organs.  The  pulse  was  rather  slug- 
gish, being  sixty-five  per  minute.  The  color  of  the  skin  and  conjunctiva 
was  somewhat  like  mahogany  ; the  urine  contained  biliverdine ; the 
stools  were  of  a clay  color  ; the  appetite  was  small  ; the  feeling  of 
strength  about  normal ; the  sleep  at  night  undisturbed. 

During  the  instituted  sublimate  treatment  the  patient  gained  con- 
tinuedly;  the  appetite  increased;  the  icteric  color  of  the  skin  and  urine 

16* 


186 


SYPHILITIC  DISEASES  OF  THE  KIDNEY. 


diminished ; the  faeces  assumed  more  and  more  their  natural  hue,  and 
lastly,  the  subjective  and  objective  symptoms  of  the  icterus  disappeared 
after  the  injection,  subcutaneously,  of  1J  gr.  of  sublimate.  Also  the 
plaques  mucqueuses  of  the  pharynx  entirely  vanished,  but  the  condy- 
lomata  on  the  labia  pudendorum  increased  so  that  it  was  necessary  to 
inject  3 gr.  more  of  sublimate. 


B.  SYPHILITIC  DISEASES  OF  THE  KIDNEY. 

There  is  yet  a certain  obscurity  about  the  syphilitic  diseases 
of  the  kidney  which  remains  to  pathological  anatomy  to  ex- 
plain more  fully,  but  we  are  able  already  to  point  out  with 
certainty  a syphilitic  interstitial  and  gummous  nephritis , and 
even  an  amyloid  degeneration  of  the  kidney ; not  only  Vir- 
chow in  his  lectures,  but  also  the  dissertation  of  Barde,* * * §  ap- 
pearing under  his  presidium.  Also,  Arn.  Beer,f  and  the 
French  authors,  especially  CornilJ  and  Lancereaux,§  have 
shown  important  necroscopic  facts  bearing  on  this  form  of 
disease  of  the  kidney.  To  use  for  these  syphilitic  affections 
of  the  kidney  a mercurial  treatment,  especially  the  subcu- 
taneous injection  of  sublimate,  might  look,  at  the  first  glance, 
rather  improper,  since  Wells,  Blakall  and  Gregory,  and  re- 
cently Pavy  and  Sackowsky,  have  stated  that  mercury  not 
only  induces  albumirmria , but  also  causes  grave  disease , as 
parenchymatous  and  amyloid  degeneration  of  the  renal  or- 
gans. 

As  older  authors,  so  in  recent  time,  Kussmaul  defended 
mercury  against  this  imputation,  and  has  shown  that,  with 

* De  Syphiliticis  Renum  AfFectionibus.  Berolini,  1863. 

j*  The  Interstitial  Syphilis.  Tubingen,  1867. 

J Memorie  sur  les  lesions  antomiques  du  rein  dans  Palbuminurie. 
These  de  Paris,  1864. 

§ Traite  de  la  Syphilis.  Paris,  1866,  p.  289. 


SYPHILITIC  DISEASES  OF  THE  KIDNEY. 


187 


workmen  who  manipulate  quicksilver,  no  albuminuria  could 
be  found,  and  those  workmen  who  applied  the  quicksilver  to 
looking  glasses,  laboring  under  disease  of  the  kidney,  had 
their  renal  affection  as  a consequence  of  an  already  existing 
tubercular  process  of  the  lungs.  To  detect  albumen  in  the 
urine,  and  to  settle  the  question,  I examined  the  secretion 
from  fifty  patients,  taking  those  who  received  the  relatively 
greater  doses  of  the  sublimate  subcutaneously.  The  ex- 
amination was  made  at  different  stages,  in  the  beginning  and 
the  further  development  of  the  disease,  and  even  at  the  end 
of  the  treatment.  Among  the  patients  there  were  even  such 
as  had  more  or  less  salivation,  and  even  some  of  them  showed 
appearances  of  intoxication  consequent  upon  abnormally 
large  doses  of  the  sublimate  being  subcutaneously  injected. 

Not  in  one  of  all  these  cases  could  I detect  a trace  of  albu- 
men, and  furthermore  I will  remark  that  I also  failed  to  find 
any  trace  of  sugar  in  the  urine . 

And,  therefore,  I am  justifiable  in  making  the  assertion, 
that  hypodermically  injected  sublimate  produces  no  affection 
of  the  kidney  which  could  be  detected  by  the  presence  of 
albumen  in  the  urine. 

Since  I consider  myself  justifiable  by  the  facts,  in  not 
attributing  to  mercury  a deleterious  effect  on  the  kidney,  my 
therapeutical  results  give  me  on  the  contrary,  the  conviction 
that  the  subcutaneous  method  in  the  first  state  of  syphilis 
might  be  of  a beneficent  character,  and  as  evidence  of  this 
view,  I produce  the  following  cases,  which  might  be  aug- 
mented by  further  illustrations. 

Concerning  the  cure  in  the  later  stages,  I am  not  able  to 
give  any  proofs.  That  the  sublimate  is  not  able  to  restitute 
the  cicatrized  tissue  of  the  kidney  as  detected  by  Virchow, 
nor  bring  about  the  functional  integrity  of  an  amyloid  de- 


188 


SYPHILITIC  DISEASES  OF  THE  KIDNEY. 


generated  tissue,  holds  good  with  the  kidney  as  with  all  other 
organs. 

To  state  that  a better  success  attends  the  subcutaneous 
method,  than  any  other  antisyphilitic  treatment  of  these 
affections,  is  impossible,  since  a greater  number  of  patients  is 
necessary  wherewith  to  make  a reliable  comparison. 

I will  only  mention  that  before  introducing  my  method,  I 
treated  two  patients  with  a long  course  of  the  sarsaparilla 
sweat-cure , the  one  being  in  the  early  and  the  other  in  the 
advanced  stage  of  the  disease.  The  result  was  rather  a 
pitiful  one.  Both  died,  and  a post-mortem  examination  re- 
vealed a diffuse  nephritis  with  the  one,  and  the  other  had  an 
amyloid  degeneration  of  the  kidney. 

The  following  are  cases  treated  subcutaneously : 


Case  67. — Ann  A.,  twenty-one  years  old,  was  received  into  the 
Charite  on  the  17th  July,  1866.  The  patient,  already  in  1865,  had  been 
in  our  wards,  on  account  of  erosions  on  the  labia  minora,  a vaginal  dis- 
charge and  small  soft  ulcerated  patches  at  the  vaginal  introitus ; she 
was  locally  treated  for  three  weeks,  March  10th,  1866,  on  account  of  diph- 
theric ulcerations  on  the  left  pudendal  lip  ; maculous  exanthem  on  the 
trunk.  The  sarsaparilla  sweat-cure  was  also  used  during  the  same 
time.  Twelve  weeks  ago,  she  was  confined  in  her  eighth  month  of 
pregnancy,  with  a child,  which  lived  six  weeks. 

Status  prsesens : the  patient  is  of  delicate,  feeble  constitution,  looking 
care-worn  and  pale.  The  face  is  someivhat  tumefied , especially  beneath  the 
eyes , besides  there  is  slight  oedema  near  the  joints  of  the  lower  extremities . 
The  following  syphilitic  appearances  are  present : condylomata  lata 
covering  the  pudenda,  at  the  left  angle  of  the  mouth,  and  near  the 
tonsils,  and  on  the  roof  of  the  mouth  ; maculous  exanthem ; loss  of 
hair;  vaginal  discharge  ; urethritis,  and  some  swelling  of  the  inguinal 
glands. 

Examination  of  the  chest  showed  the  existence  of  a slight  bronchial 
catarrh.  The  urine  was  acid , containing  much  albumen , a little  blood , 
bladder  epithelium , fibrine  cylinders  and  oil  globules.  Temperature  37.6 
Celsius,  pulse  84,  appetite,  bowels  and  sleep,  normal. 


SYPHILITIC  DISEASES  OF  THE  KIDNEY. 


189 


We  used  at  once  subcutaneous  injections  of  sublimate,  giving  gr. 
doses  for  two  days.  The  quantity  of  urine  passed  in  twenty-four  hours , 
consisted  of  1500  centimeters  with  a specific  gravity  of  1013.  Afterwards  we 
gave  £ gr.  doses. 

The  patient  complaining  of  great  pain  in  the  kidney  regions,  we  ap- 
plied six  cups.  Up  to  the  twelfth  injection  (1J  gr.  sublimate  being 
used  nearly)  no  change  for  the  better  was  visible.  Also  in  the  quality 
and  quantity  of  urine  there  was  no  alteration. 

But  soon  the  oedema  disappeared,  and  we  could  detect  no  fihrine  or  blood 
corpuscles  in  the  urine . The  albuminous  ingredient  was  lessened.  After 
the  thirteenth  injection  salivation  had  already  occurred.  At  the  same 
time  the  patient  complained  of  great  headache,  nausea,  vomiting  and 
vertigo.  The  urine  was  again  tinged  with  blood  and  albumen , the  specific 
gravity  being  1012  and  the  quantity  1600  cubic  centimeters. 

On  the  following  day,  the  blood  increased  in  the  renal  secretion,  and 
also  the  headache,  with  severe  pain  in  the  knee  joint.  The  patient  was 
very  feeble  ; restless  sleep  ; appetite  and  stools  were  wanting.  Again 
six  cups  were  applied  to  the  sacral  region,  and  I prescribed  confection 
of  senna  for  the  bowels  and  used  tannin  and  opium. 

After  the  fourteenth  day,  the  condition  of  the  patient  improved.  But 
on  account  of  the  non-disappearance  of  the  syphilitic  symptoms  we 
used  again  the  hypodermic  injections,  besides  the  tannin.  After  the 
third  injection  of  gr.,  the  blood  and  albumen  in  the  urine  disappeared. 
The  quantity  increased  to  2000  cubic  cent.,  the  specific  gravity  being  from  1015 
to  1010.  The  color  was  a pale  yellow.  The  maculous  syphiloid  faded 
out,  and  I discharged  the  patient  after  using  altogether  3 gr.  of  the  sub- 
limate. Several  months  after,  the  patient  returned  again  to  our  wards, 
November  10,  1866.  Her  appearance  was  healthy,  and  she  said  she  had 
been  well  since  her  discharge.  Of  constitutional  symptoms  of  syphilis, 
no  trace  was  left.  There  was  only  acuminata  on  the  labia,  an  ulcus 
molle  on  the  introitus  vaginae,  besides  fluor  vaginalis  and  urethritis. 
The  urine  was  of  normal  consistency  and  free  from  fibrine  cylinders , albumen 
and  blood.  Two  days  after  admission,  the  patient  was  taken  with  a pro- 
fuse diarrhoea  which  was  checked  by  opium.  We  discharged  her  Nov. 
24th. 

After  six  months,  Anna  A.,  was  again  received  into  the  Charite  on 
June  6,  1867. 

An  examination  of  the  quite  healthy  appearing  patient,  revealed 
eroded  condylomes,  like  excrescences,  on  the  labia  majora,  and  in  the 
vicinity  of  the  anus ; vaginal  discharge ; an  abcess  on  the  right  gland 


190 


SYPHILITIC  DISEASES  OF  THE  KIDNEY. 


of  Duverney  ; the  lymphatic  glands  only  in  the  inguinal  region  were 
swollen.  On  account  of  the  not  well  marked  character  of  these  excres- 
cences, we  used  only  a local  treatment  of  argentum  nitricum,  which 
produced,  in  three  weeks,  a complete  cure. 

It  is  noticeable  in  this  case,  that  the  patient  was  suffering  from  a 
stomatitis  which  had  the  character  of  a mercurial  one,  although  the 
patient  denied  having  used  any  preparation  of  mercury.  Gargarisms  of 
chlorate  of  potassa  cured  this  affection. 

Case  68. — Fred.  S.,  a laborer,  eighteen  years  old,  was  received  April 
1,  1868,  into  our  wards.  Patient  says  he  had  a chancre  four  months 
ago,  and  a skin  affection  following  in  two  months  thereafter. 

Status  prsesens : The  patient  has  flabby  muscle  and  a delicate  habitus; 
looks  pale,  and  the  visible  mucous  membrane  seems  anaemic.  He  com- 
plains of  a frequent  desire  to  urinate ; shooting  pains  in  the  lumbar 
region,  and  a dizziness  and  pain  in  the  head.  He  particularly  complains 
of  a lack  of  air  which  he  feels  once  in  awhile.  Examination  revealed  oedema 
of  the  face,  arms , feet  and  moderate  ascites.  The  quantity  of  urine  daily  passed 
is  from  800  to  900  cubic  cent.,  with  a specific  gravity  of  1019,  of  a brown 
color.  Microscopic  examination  shows  it  to  contain  blood  corpuscles,  albumen, 
and  fibrine  cylinders  quite  abundantly.  Of  syphilitic  appearance,  I found 
on  the  back,  the  upper  and  lower  extremities  ecthymatous  ulcers  of  the 
size  of  a penny,  which  did  not  reach  very  deeply  into  the  skin.  The 
inguinal  and  cervical  lymphatic  glands  were  much  swollen.  In  the  nose 
were  superficial  ulcerations,  on  the  mucous  membrane  which  secreted 
profusely  pus  and  mucus.  Exploration  of  the  chest  and  abdomen  revealed 
nothing  abnormal.  The  heart’s  sound  at  the  apex  was  very  loud  and 
strong;  vesicular  respiration  is  sometimes  augmented;  liver  and  spleen 
normal. 

Although  the  patient  was  dropsical,  we  thought  the  use  of  the  subli- 
limate  was  indicated  because  we  had  the  opinion  that  syphilis  was  the 
cause  of  the  nephritic  affection. 

We  used  at  once  J gr.  subcutaneously,  the  next  day  reducing  the  dose 
to  l gr.  After  the  sixth  injection,  or  the  use  of  1 J gr.  of  sublimate,  the 
general  feeling  of  the  patient  was  better,  the  dyspnoea,  especially,  being 
diminished.  The  anasarca  and  ascites  were  considerably  reduced;  urine 
was  voided  more profusely , and  increased  after  the  use  of  2\  gr.  to  4000  cubic 
cent.,  the  specific  gravity  being  1021.  The  color  was  yellow,  but  somewhat 
clouded  on  account  of  mucus  being  present . Albumen  or  fibrine  cylindroids 
could  not  be  detected  nor  blood  corpuscles . 


SYPHILITIC  AFFECTIONS  OF  THE  BRAIN. 


191 


A continuation  of  the  injections  completed  the  cure,  the  subjective 
and  objective  symptoms  entirely  disappearing.  The  ozaena  and  ecthyma 
were  healed,  and  we  were  able  to  discharge  the  patient  after  the  use  of 
2f  gr.  of  the  sublimate. 


C.  SYPHILITIC  AFFECTIONS  OF  THE  BRAIN. 

What  we  have  asserted  of  syphilis  in  general,  holds  good 
concerning  syphilis  of  the  brain. 

It  exists  much  oftener  than  is  generally  supposed.  If  we 
take  the  many  post-mortems  and  the  lesions  found  there  in 
the  central  nerve  apparatus,  which  can  be  pronounced  with 
more  or  less  certainty  as  residues  of  a preceding  syphilitic 
process,  the  opinion  will  force  itself  upon  us,  that  in  the  ma- 
jority of  cases,  a wrong  diagnosis  allowed  the  fatal  issue. 
Among  the  instances  are  to  be  classed  apoplexy,  hemiplegia 
paralysis,  epilepsy  and  even  psychosis,  mania,  hallucinations, 
melancholy,  &c.  Prof.  Jaksch  of  Prague,  says,  in  his  valu- 
able paper*  on  syphilis  of  the  internal  organs,  in  a very 
characteristic  way,  that  “a  revision  of  the  hospital  and  in- 
sanity cases  would  show  that  syphilis  is  too  little  looked  upon 
as  a cause  of  mental  derangement.' ’ 

Concerning  the  pathological  and  anatomical  changes  in 
the  brain  suffering  from  syphilis,  the  symptoms  are  more 
manifold  even  than  they  are  in  syphilis  of  the  skin.  But  it 
is  to  be  regretted  that  they  are  not  yet  known  in  their 
characteristics,  nor  anatomically  specified. 

In  recent  times  again,  Virchow  has  been  the  first  to  clear 
up  the  obscurity  in  this  branch  of  science,  which  may  give 
rise  to  still  more  important  developments  in  the  future.  The 
gummata  are  not  to  be  looked  upon  as  the  only  manifestation 


* Prager  Medicinische  Wochenschrift.  1864,  No.  1-50. 


192 


SYPHILITIC  AFFECTIONS  OF  THE  BRAIN. 


of  syphilis.  We  know  that  the  disease  holds  on  to  its  poly- 
morphous character,  causing  not  only  specific  irritations  in 
the  form  of  thickenings,  vegetative  growths,  granulations, 
and  even  condylomatous  excrescences.  Besides  these  mani- 
fold syphilitic  processes,  we  find  that  even  the  different  parts 
of  the  brain  may  be  the  seat  of  syphilitic  degeneration. 

Not  only  the  dura  mater  on  its  outer  and  inner  surface, 
and  semilunar  prolongation  is  visited  by  syphilis,  but  also 
the  pia  mater,  arachnoidea,  ependyma  and  even  the  greater 
and  lesser  brain.  And  here  the  syphilis  is  not  only  concen- 
trated on  the  one  or  the  other  part,  but  it  may  attack  the 
substance  of  the  hemispheres,  also  the  large  ganglions,  thala- 
mus opticus,  pons  varioli,  pedunculi  cerebri  and  cerebelli. 

The  danger  of  brain  syphilis  does  not  wholly  consist  in 
the  fact  that  a single  part  of  this  organ  suffers  disorganiza- 
tion, but  that  a disturbance  is  also  caused  in  the  nearest  sur- 
roundings, thus  complicating  the  affection.  We  see  that  the 
single  tissue  by  the  exudative  inflammation,  may  take  on  the 
growing  process  here,  the  fatty  metamorphosis  there,  and 
the  nerves  which  are  exposed  to  pressure  will  become  atro- 
phied, and  the  blood-vessels  §lso  obliterated.  By  this  latter 
process,  we  may  explain  the  apoplexies  which  have  always 
been  witnessed  with  syphilis,  as  existing  in  some  mysterious 
manner.  Such  revelations  belong  to  recent  investigations, 
and  Virchow  was  the  first  who  proved  an  obliteration  of  the 
carotis  cerebralis.  Similar  cases  may  be  found  in^the  pub- 
lications of  this  distinguished  author,  especially  in  his  work 
on  Malignant  Tumors,  Vol.  II.,  p.  451. 

It  is  not  the  place  here  to  detail  those  pathological  pro- 
cesses occurring  in  the  central  nervous  apparatus.  But  I 
will  not  omit  this  occasion  to  repeat  again  that  pathological 
anatomy,  coupled  with  clinical  observations,  will  be  able  to 


SYPHILITIC  AFFECTIONS  OF  THE  BRAIN. 


193 


contribute  to  a better  knowledge  of  brain  syphilis.  It  will 
be  able  to  do  it  very  often.  In  post-mortem  examinations 
wre  generally  find  the  last  products  of  syphilitic  degeneration, 
L e.j  the  coarser  material  changes,  while  on  the  other  hand 
the  finer  beginnings  may  be  found,  very  probably,  by  the 
help  of  clinical  observations. 

We  must  consent  that  a peculiarly  formed  tissue  like  the 
syphilitic  does  not  cause  a difference  in  the  quality  of  the 
functional  disturbance  produced  by  it,  but  there  are  always 
starting  points  which  may  assure,  either  in  a positive  or 
negative  manner,  a diagnosis  in  syphilis.  To  the  former  be- 
long the  antecedents  of  the  patient,  the  coincidence  of  syphi- 
litic affections  in  other  organs,  their  development,  chronolo- 
gical data,  the  intensity  of  single  symptoms,  the  remission 
and  exacerbation  as  to  headache,  especially  at  night.  The 
negative  points  are  the  exclusion  of  all  etiological  symptoms 
based  on  an  accurate  examination  of  all  organs  of  the  patient. 

As  to  the  therapeutical  indications  for  brain  syphilis,  res- 
toration of  the  destroyed  nerve  tissue  is  out  of  the  question. 
A nerve  cell  destroyed  by  inflammation,  or  on  account  of 
pressure  or  fatty  metamorphosis,  cannot  be  restored  ad  in- 
tegrum; neither  can  a brain  mass  despoiled  by  haemorrhagic 
detritus  be  replaced  in  its  normal  condition.  The  same  is 
the  case  with  vessels  which  have  become  impermeable  by  an 
adherent  thrombus.  We  are  glad  to  say,  however,  that  these, 
described  processes  are  the  last  phases  of  syphilitic  disease. 
In  the  earlier  stages  treatment  may  cause  a certain  healing 
by  involution  and  absorption  after  a regressive  metamorphosis, 
or  at  least  it  may  stay  the  further  development  of  the  affec- 
tion. It  seems  that  the  connective  tissue  of  the  brain, 
encircling  it  in  its  coarse  and  fine  rugae,  and  its  pathological 
proliferation  may  take  on  a retrogressive  metamorphosis  in 
17 


194 


SYPHILITIC  AFFECTIONS  OF  THE  BRAIN. 


consequence  of  a therapeutical  treatment,  just  as  do  the 
outer  integuments  of  the  body  which  are  histologically  similar 
in  tissue.  As  the  inflammatory,  exudative  and  condylomatous 
prolific  granulations  of  the  skin  and  mucous  membrane,  and 
even  the  periosteal  layers  of  bone  are  undergoing  changes  by 
the  absorptive  process,  so  also,  the  histologically  similar 
tissues  of  the  brain,  pia  and  dura  mater,  arachnoidea, 
ependyma,  &c.,  or  the  adventitious  tissue  of  the  vessels  in 
the  cranium  may  undergo  the  same  pathological  processes. 
That  “ absorption  may  diminish  and  eradicate  the  gummy 
knots  in  the  brain,”  Virchow  has  already  pointed  out.  It 
almost  seems,  according  to  his  researches  in  pathology,  that 
gummous  formations  in  the  brain,  change  not  so  frequently 
into  the  more  dangerous  puriform  metamorphosis  as  the  same 
constructed  tumors  of  the  skin  and  bones,  and  that  here  fatty 
metamorphosis  is  always  favorable  in  prognosis. 

This  view  might  be  taken  at  first  glance  as  a hypothetical 
one,  but  it  is  fully  confirmed  by  many  clinical  cases,  well 
authenticated,  in  which  cerebral  syphilis  was  healed  by  a 
timely  antisyphilitic  treatment.  Our  medical  literature  con- 
tains the  record  of  very  many  syphilitic  brain  affections, 
which  either  by  mercury  or  iodide  of  potassium  have  been 
wholly  eradicated.  Among  these  are  paralysis,  epilepsy,  and 
psychosis  of  every  description.  I refer  to  Yvaren,  Sandras, 
Brach,  Baumes,  Romberg,  Trousseau,  Jaksch,  &c. 

I will  remark  here,  a very  significant  fact  for  practice, 
that  all  those  remedies  which  had  a result,  especially  the 
mercurials,  have  been  used  not  only  once,  but  frequently  and 
energetically.  Romberg,  in  his  work  on  “ Diseases  of  the 
Nervous  System,”  p.  918,  says  emphatically,  “If  anywhere 
a correct  diagnosis  may  save  a patient,  it  is  especially  true 
with  these  paralyses.  The  specific  remedies  are  mercury  and 


SYPHILITIC  AFFECTIONS  OF  THE  BRAIN. 


195 


iodide  of  potassium , which  accomplish  ivonders  here ; but 
their  use  must  be  persevered  in  sufficiently  long.  Also  the 
decoctum  Zittmanni  is  a suitable  remedy  here.”  The  fear 
that  a forced  use  of  these  remedies  might  be  dangerous  to  the 
nerve  apparatus,  seems  to  be  without  foundation.  Ottensee 
has,  in  one  of  his  works,  a hesitancy  in  regard  to  the  dele- 
terious effects  of  these  drugs,  but  it  has  not  been  verified  in 
the  least,  and  the  most  accurate  observers  have  failed  to  find 
any  evidence  to  substantiate  his  statement. 

My  own  cases,  where  I have  had  opportunity  to  observe 
the  effect  of  the  sublimate,  subcutaneously  used,  have  not 
been  numerous,  because,  as  already  said,  the  patients  having 
these  diseases  were  sent,  very  frequently,  to  other  wards  on 
account  of  a wrong  diagnosis. 

I never  saw,  in  my  patients,  syphilitically  affected,  even 
in  those  grave  forms  which  are  apt  to  be  connected  with 
syphilis  of  the  nerves,  a transformation  of  the  disease  to  the 
nervous  apparatus,  which  may  be  owing  to  the  quick  regres- 
sive course  of  the  syphilis  caused  by  the  subcutaneous  in- 
jections. 

How  and  in  what  manner  my  method  excels  other  ordinary 
treatments  for  syphilis  of  the  cerebral  organs,  I cannot  de- 
cide for  want  of  comparing  material.  I had  several  patients 
in  my  private  practice,  especially  with  hemiplegia,  but  on  ac- 
count of  their  leaving  town,  I cannot  give  any  accurate 
statement  concerning  their  recovery,  and  therefore  I must 
fall  back  on  my  few  cases  in  the  Charity.  I must  say  here 
that,  although  my  patients  improved  rapidly,  I have  not  a 
single  case  of  a total  cure  to  chronicle,  probably  because 
several  were  satisfied  with  their  improved  condition,  and  left 
the  hospital,  while  others  were  sent  by  us  to  other  wards  as 


196 


SYPHILITIC  AFFECTIONS  OF  THE  BRAIN. 


nervously  and  mentally  deranged  patients,  where  was  abetter 
convenience  for  those  of  this  class. 

The  following  are  the  cases  in  question : 

Case  69. — E.  F.,  a merchant,  thirty-one  years  old,  descending  from  a 
healthy  family,  suffered,  in  1863,  from  a hard  chancre,  and  used  for  the 
same  inunction  for  three  weeks.  Two  months  after  he  had  a papulous 
exanthem  on  the  forehead,  for  which  he  took,  during  five  weeks,  Dzondi’s 
pills,  and  later  iodide  of  potassium.  He  noticed,  eight  weeks  afterwards, 
a hoarseness  and  a painfulness  in  deglutition.  He  now  used  Zittmann’s 
treatment  as  prescribed.  During  the  war  in  Schleswig-Holstein,  1864, 
after  a great  deal  of  service,  he  suffered  suddenly  from  paraplegia  of  the 
lower  extremities.  After  a number  of  foot-baths,  and  the  use  of  mineral 
water,  the  paralysis  of  the  right  foot  disappeared,  the  left  remaining  in 
its  paralyzed  condition.  He  had  great  torpidity  of  the  bowels  ; catarrh 
of  the  bladder,  and  paralysis  of  the  same.  At  his  admission,  July,  1865, 
we  found  the  following  conditions : feebly  built,  flabby  muscles,  and  a 
paleness  of  the  visible  mucous  membrane  ; myopia  of  both  eyes  ; senso- 
rium  perfectly  clear  ; no  paralytic  symptoms  in  the  region  of  the  nerves 
of  hearing  ; tongue  has  a yellowish  coat ; appetite  good ; abdomen 
tympanitic  ; stools  produced  only  by  laxatives  ; dullness  over  the  hepa- 
tic region ; spleen  normal ; thorax  well  built  and  normal ; respiration, 
costo  abdominal.  Auscultation  and  percussion  does  not  reveal  anything 
abnormal.  Dullness  of  the  praecordial  region  of  normal  extent.  Heart 
sounds  clear.  Pressure  over  the  well  proportioned  spinal  column  not 
painful.  Both  lower  extremities  were  of  the  same  length  as  shown  by 
accurate  measurement  from  the  spinae  il.  ant.  sup.  The  malleoli  and 
knee-joint  were  upon  the  same  level.  When  lying  quietly  on  the  back, 
the  use  of  both  extremities  is  not  affected  with  the  exception  of  a slight 
impairment  of  the  left.  Sensitiveness  is  normal.  In  the  erect  position , 
the  patient  rests  more  on  the  right  than  on  the  left  foot)  in  consequence  of  which 
the  whole  of  the  left  side  of  the  body  seems  somewhat  lax.  The  left  shoulder 
is  some  lower  than  the  right.  Pressure  on  the  spinous  processes  of  the 
sacral  region  causes  no  pain.  In  walking  the  left  foot  is  raised  but  a little 
from  the  ground.  Patient  drags  the  same , assuming  thereby  a shuffling  gait. 
The  mentioned  paralysis  of  the  bladder  still  exists , the  patient  being  unable  to 
retain  his  urine.  Constipation  still  obstinate  and  only  by  strong  laxa- 
tives can  the  bowels  be  moved.  Pressure  over  the  region  of  the  bladder 
causes  no  pain.  On  the  scrotum  and  penis  there  are  several  erosions. 


SYPHILITIC  AFFECTIONS  OF  THE  BRAIN. 


197 


In  catheterizing  the  patient  with  an  elastic  catheter,  we  encounter  a 
hindrance  in  the  vicinity  of  the  prostate  gland.  By  an  examination, 
per  rectum,  we  find  the  middle  lobe  of  the  prostate  some  swollen  and  very 
sensitive  to  the  touch.  Urine  is  alkaline,  of  a clay  color,  with  a milky 
white  sediment.  Electricity  is  more  sensibly  felt  on  the  paralyzed  ex- 
tremities than  on  the  sound. 

We  believed,  from  the  previous  history,  we  had  to  deal  with  a syphi- 
litic paralysis,  and  our  opinion  was  strengthened  in  this  view  by  the 
absence  of  other  etiological  momenta  tending  to  a different  diagnosis. 
But  I resolved  not  to  use  the  sublimate  injection  at  once,  and,  there- 
fore, prescribed  iodide  of  potassium  internally  with  galvanism.  This 
treatment  resulted  in  bettering  the  condition  of  the  paralyzed  bladder. 
But  the  paresis  of  the  loiver  extremities  existed  in  the  same  degree,  therefore, 

I thought  myself  justified  in  using  the  sublimate  injections . We  injected 
daily  gr.  sublimate  hypodermically.  After  the  use  of  twenty  injections, 
or  2}  gr.  of  sublimate,  a decided  improvement  in  the  movements  of  the 
lower  extremities  could  be  seen.  After  the  further  injection  of  1 gr. 
more,  the  movements  were  almost  normal.  The  patient  was,  unluckily, 
satisfied  and  left. 

Case  70. — H.,  a druggist,  forty-one  years  old,  was  received  into  out- 
wards January  1,  1866.  The  antecedent  history  of  the  patient,  on  ac~ 
count  of  indistinct  utterance  from  paralyzed  vocal  cords,  proved  very  unsatis- 
factory. Only  after  improvement  had  taken  place,  could  we  get  the 
following  from  the  patient : In  May,  1865,  he  contracted  a hard  chancre 
on  the  prepuce,  and  used  as  a remedy  about  50  gr.  calomel,  according 
to  his  statement.  But  the  syphilis  reappeared,  under  the  form  of  a 
maculous  exanthem,  in  October  of  the  same  year.  He  used,  without 
consulting  a physician,  hydragyrum  iodatum  rubrum  etflavum.  But  seeing 
no  result  from  this  treatment,  he  used  iodide  of  potassium,  and  a certain 

II  wood  tea.”  Shortly  after  he  had  loss  of  memory  and  confused  thoughts , 
accompanied  with  aphasia,  so  that  his  relatives  brought  him  to  the  hospital 
in  the  following  condition  : 

Feeble,  emaciated  body ; flabby  muscles  ; a paleness  of  the  visible 
mucous  membrane  ; apathetic  expression  of  the  countenance,  with  a 
somewhat  fixed  gaze  ; pupils  of  equal  size,  reacting  normally  to  the 
light ; patient  follows  the  movements  of  objects  placed  before  him  only 
for  a short  time.  In  the  nerves  of  the  face  no  paresis  is  discoverable. 

Physical  examination  of  the  organs  of  the  chest  and  abdomen  reveals 
nothing  important,  only  the  sound  in  the  left  supraclavicular  region  is 

17* 


198 


SYPHILITIC  AFFECTIONS  OF  THE  BRAIN. 


rather  higher  than  normally  it  should  be,  while  the  sound  of  the  left 
regio-supraspinata  is  a trifle  duller.  Auscultation  shows  nothing  very 
abnormal,  excepting  the  breathing  is  irregular  and  feeble.  The  mani- 
fold entreaties  made  to  the  patient  for  deeper  respiration  are  not  no- 
ticed ; mucus  sputa  is  expectorated  ; no  abnormal  sensibility  of  the 
spinal  column  can  be  made  out ; during  the  decubitus  of  the  patient, 
the  left  upper  extremity  is  straight,  while  the  right  is  moderately  flexed, 
and  sometimes  is  taken  with  clonic  twitchings.  Similar  convulsive  movements 
are  noticed  with  the  right  lower  extremities , especially  in  the  vicinity  of  the 
musculus  rectus  femoris.  The  arm  and  foot  being  lifted , they  both  fall  down 
helpless.  But  the  patient  himself  is  able , after  repeated  urging , to  raise  these 
extremities , but  visibly , with  great  exertion.  The  right  could , after  repeated  and 
fruitless  efforts , be  slightly  raised.  To  flex  the  arm  is  impossible , and  he  al- 
ways fails  with  this  arm  in  reaching  objects  placed  before  him.  The  right  lower 
extremity  is  colder  to  the  touch  than  the  upper  one . Requesting  the  patient  to 
make  pressure  with  his  hands , it  is  evident  that  the  left  is  weaker  than  the  right. 

The  sensitiveness  to  electricity  is  very  much  lessened  in  the  muscles 
of  extension,  so  that  only  with  a strong  current  can  the  right  leg  be  ex- 
tended. Only  after  several  trials  is  the  patient  able  to  raise  himself  from  the 
bed , and  this  is  generally  effected  by  the  help  of  the  left  arm.  He  can  stand 
erect , but  very  imperfectly . With  closed  eyes , he  staggers  and  falls  if  unas- 
sisted. In  trying  to  micturate  in  an  erect  position  he  falls  to  the  left  side.  He 
urinates  very  slowly,  and  after  finishing,  quite  a quantity  drips  away. 
The  urine  is  weakly  acid,  rather  cloudy,  but  contains  no  abnormal  in- 
gredients. Asking  him  about  pain,  he  points  to  his  forehead,  and  never 
gives  any  other  details  respecting  pain.  Deglutition  is  good  ; the  uvula 
hangs  down  lax  and  straight ; the  tongue,  when  pointed  from  the  mouth) 
has  a tremulous,  unsteady  motion  ; the  functions  of  mastication  are 
normal. 

As  to  syphilitic  appearances,  a small  papulous  exanthem  coveied  with 
small  scales  is  remaining  partly  in  an  aggregated  and  partly  in  a dif- 
fuse configuration.  On  the  forehead,  besides  the  single  papules,  there 
are  dark-brown  pigment  patches.  There  are  small  erosions  on  the  right 
tonsils.  The  inguinal  and  cubital  glands  are  much  swollen,  but  the 
cervical  only  slightly. 

The  instituted  therapeutics  consisted  of  the  administration  of  iodide 
of  potassium,  electrifying  the  paralyzed  parts  together  with  good  diet. 
But  these  symptoms  were  becoming  more  aggravated.  One  morning, 
we  found  the  patient  helpless  upon  the  floor.  Probably  he  fell  while 
trying  to  urinate.  He  could  not  relate  why  he  was  out  of  the  bed,  but 


SYPHILITIC  AFFECTIONS  OF  THE  BRAIN. 


199 


pointed  to  the  urine  vessel.  By  long  standing  and  with  efforts  to  urinate , 
tremor  and  twitching  occurs  on  the  right  side,  especially  in  the  right  arm , 
which,  with  this  exception , seems  less  sensitive . The  dribbling  away  of  the 
urine  has  caused  several  excoriations  on  the  scrotum.  On  the  sacral 
region,  bed  sores  have  formed. 

After  using  ljg  of  iodide  of  potassium  during  twelve  weeks,  the 
faculty  of  speech  was  improved,  but  not  very  greatly,  so  that  he  could 
utter  single  words,  but  no  coherent  sentences.  The  hemiplegic  ap- 
pearances were  not  much  changed. 

Five  months  after  admission,  we  began  the  use  of  subcutaneous  in- 
jections of  sublimate  in  gr.  doses.  Already  after  the  use  of  1 gr.,  the 
patient  was  able  to  elevate  the  right  arm  and  flex  it . But  the  right  leg  did 
not  improve  so  much.  In  the  ankle  joint  particularly,  he  could  make 
no  spontaneous  movement ; but  he  could  open  and  close  the  right  hand  quite 
well.  He  could  stand  erect  but  for  a short  time  only . The  faculty  of  speech 
improved , but  it  was  not  quite  normal.  Examination  now  of  the  mentally 
improved  patient,  revealed  that  the  functions  of  the  right  eye  and  right 
ear  are  impaired,  as  compared  with  the  left.  The  bones  of  the  head 
are  not  very  sensitive.  On  all  parts  of  the  body  he  feels  quite  readily  a 
pricking  with  needles,  and  locates  the  points  very  well.  The  tempera- 
ture of  both  sides  of  the  body  is  the  same. 

After  the  use  of  1 gr.  more  of  the  sublimate,  the  patient  himself 
notices  his  improvement.  With  the  right  arm  and  leg  all  movements  are 
made , although  rather  slowly  yet  correctly.  There  was  improvement  daily. 
The  articulation  was  better,  so  that  he  could  speak  slowly,  but  co- 
herently. In  this  condition  he  was  taken  home  by  his  friends.  We 
used,  altogether,  with  this  patient,  4J  gr.  of  sublimate. 

Case  71. — Martin  Sch.,  day  laborer,  twenty-seven  years  old,  was  re- 
ceived into  the  Charite  Jan.  29,  1869.  I did  not  see  the  patient  myself 
when  received.  He  said  that  he  contracted  a chancre,  which  disap- 
peared itself  after  the  use  of  mercurial  pills.  The  patient  is  of  medium 
size,  and  of  a very  strong  constitution.  Concerning  the  syphilis  per- 
taining to  him,  we  found  on  examination,  a great  portion  of  the  surface 
of  the  body,  especially  the  trunk  and  extremities,  covered  with  a lenti- 
cular, papulous  exanthem  in  the  desquamative  stage,  with  occasionally 
dark  pigment  patches.  On  the  prepuce  in  the  neighborhood  of  the 
sulcus  retro  glandularis,  there  was  a cicatrix,  rather  soft  to  the  touch. 
The  hair  easily  came  out.  The  lymphatics  were  swollen  in  the  inguinal 
and  cervical  region. 


200 


SYPHILITIC  AFFECTIONS  OF  THE  BRATN. 


Ophthalmoscopic  inspection  revealed  a specific  retinitis , on  account  of 
which  the  patient  was  sent  to  the  ophthalmic  wards  of  Dr.  Yon  Graefe, 
where  he  also  complained,  for  the  first  time,  of  nausea  and  general 
weakness.  The  ophthalmoscopic  examination  showing  an  inflammatory 
action  of  the  eye,  the  application  of  an  artificial  leech  was  prescribed. 
Before  commencing  this  small  operation,  the  patient  was  suddenly  taken 
with  dizziness , swooning  away , but  soon  recovered  his  consciousness . The 
artificial  leech  was  applied,  extracting,  however,  but  little  blood.  In 
returning  the  patient  to  the  syphilitic  wards,  he  was  again  taken  with 
vertigo , which  soon  subsided , but  according  to  the  nurses  accompanying  him)  he 
was  unable  to  utter  a word. 

In  our  wards , shortly  after , the  patient  was  taken  with  paresis  of  the  right 
facialis  and  hypoglossus.  The  expression  was  rather  apathetic , the  right  angle 
of  the  mouth  being  drawn  down  in  a lax  manner , and  the  right  nostril  was 
narrowed , and  did  not  dilate  with  respiration.  The  nerve  fibres  belonging 
to  the  musculus  orbicularis,  palpebrarum,  corrugator  supereilli  and 
frontalis,  were  not  so  much  paralyzed.  In  asking  him  to  show  his  tongue 
the  same  could  be  done  only  very  imperfectly , the  point  being  extended  towards 
the  right . Our  efforts  to  make  the  patient  speak  were  fruitless.  It  was  im- 
possible to  get  any  sure  evidence  as  to  the  integrity  of  the  psychical  functions , 
on  account  of  this  decided  glosso-plegia.  Every  admonition  for  him  to  exe- 
cute voluntary  muscular  movements  had  to  be  repeated  before  it  was 
obeyed,  and  the  movement  then  was  of  an  unsatisfactory  character.  The 
condition  of  the  patient  changed  during  the  day  very  much.  First  paresis  of 
the  right  arm  occurred , with  complete  sensibilty  and  reflex  action  remaining. 
Afterwards  cataleptic  symptoms  were  present.  In  telling  the  patient  to  do 
something,  he  executed  the  request,  but  remained  in  the  same  position 
till  changed  by  some  one  else. 

The  following  day  nothing  more  of  these  appearances  was  present, 
but  paresis  of  the  right  arm  was  developed  to  complete  paralysis  ex- 
tending to  both  right  extremities.  Also  the  partial  paresis  of  the  region 
of  the  face  was  increased  and  fully  developed,  the  next  day.  All  the 
other  functions  of  the  body  were  entirely  normal.  Examination  of  the 
organs  of  the  chest  and  abdomen  revealed  nothing  out  of  the  natural 
order.  The  heart  sounds  were  especially  clear,  and  the  extent  of  dull- 
ness normal.  Urine  was  acid,  of  a pale  brown  color,  containing  nothing 
abnormal.  Temperature  38.2  Cel.,  pulse  94. 

On  account  of  the  named  syphiloids  and  the  retinitis,  and  a deficiency 
of  any  other  etiological  cause  for  the  apoplectic  symptoms,  I thought 
myself  justifiable  in  diagnosing  syphilitic  disease  of  the  brain , and  there- 


SYPHILITIC  AFFECTIONS  OF  THE  BRAIN. 


201 


fore  I began  at  once  the  antisyphilitic  cure  with  injections  of  sublimate 
in  doses  varying  from  J gr.  to  \ gr.  each. 

After  using  2 gr.  I could  notice  some  change  for  the  better.  The 
sensorium  was  free  ; the  patient  could  execute  movements  in  the  sound 
part  with  quick  and  exact  cordination  of  the  muscles ; the  function  of 
speech  returned,  but  in  a slight  degree.  Single,  short  words  like  “ good,” 
and  “ thank,”  he  could  speak  plainly  without  stammering ; also  the 
paresis  of  the  facialis  was  greatly  diminished,  the  corrugator  supercilli 
and  frontalis  regained  their  function.  The  right  eyelid  from  long  closure 
trembled  and  had  an  unsteady  motion.  The  muscles,  labii  superioris, 
alaeque  nasi,  zygomatici,  &c.,  were  still  under  the  influence  of  the  paresis. 
The  point  of  the  tongue  was  still  a good  deal  drawn  towards  the  right 
when  thrust  from  the  mouth.  The  movement  of  the  right  lower  extremi- 
ties was  somewhat  improved,  but  the  left  less  so.  Vision  in  the  affected 
eye  was  much  better,  and  the  mental  capacity  almost  wholly  restored. 
After  using  2 gr.  more  the  patient  was  able  to  flex  the  right  forearm  to 
a right  angle,  but  he  could  not  raise  the  upper  arm  himself  nor  bend  a 
finger  in  the  hand.  The  patient  was  not  able  to  stand  erect.  He  can 
take  only  a few  steps  when  supported  on  the  right  side  ; tongue  drawn 
towards  the  right  when  extended ; articulation  in  short  sentences,  slow 
but  indistinct.  The  alphabet  he  repeats  to  the  letter  UT,”  when  he  gets 
uneasy,  moves  the  head  in  an  unquiet  way,  and  afterwards  the  whole 
body  trembles.  The  situation  of  the  mouth  is  a trifle  one-sided,  and 
the  right  nostril  slightly  dilatable.  All  the  muscles  about  the  face 
work,  excepting  the  musculus  risorius  santorini.  After  using  4 gr.  more, 
the  retinitis  was  completely  gone)  and  the  yet  existing  paresis  appearances  of  the 
facialis  and  tongue  had  entirely  disappeared , but  articulation  was  rather 
difficult.  The  muscles  which  elevate  the  arm,  and  the  extensors  of  the 
fingers  were  not  quite  restored,  notwithstanding  the  use  of  electricity. 
The  right  foot  also  was  dragged  along  in  walking. 

As  I did  not  expect  a further  result  from  my  antisyphilitic  treatment, 

I sent  the  patient  for  further  faradisation  to  the  nervous  wards  of  Pro- 
fessor Westphal. 


202 


RESPECTING  SUBLIMATE  INJECTIONS. 


VI.  — CONSIDERATIONS  RESPECTING  SUBLIMATE 
INJECTIONS. 

Haying  already  considered  the  general  pharmacodynamic 
effect  of  sublimate  on  the  healthy  and  diseased  organs,  and 
the  eventualities  of  a pernicious  effect  of  this  medication  on 
the  blood,  nervous  system  and  other  organs,  it  seems,  at  a 
first  glance,  unnecessary  to  discuss  again  the  question  of 
contraindication.  But  I consider  it  necessary  to  name  here 
special  momenta  in  which  injections  of  sublimate  are  either 
partly  or  wholly  contraindicated.  These  momenta  are  espe- 
cially age,  sex,  dyscrasia  or  already  existing  diseases. 

Age. — Generally  I never  treated  children  in  their  first 
years  of  life  with  injections,  although  such  experiments 
have  been  made,  I hear,  in  Vienna  with  complete  success. 
I refrained  here  from  giving  the  injections,  because  a part 
of  the  advantages  to  be  gained  with  the  adult — as  the  ability 
to  work,  &c. — does  not  pertain  to  the  age  of  childhood ; and 
the  pain  of  the  operation  is  to  be  borne  in  mind,  on  account 
of  the  will  power  to  withstand  it  being  absent  in  the  young 
organism.  As  yet,  I have  only  treated  one  child,  a girl  of 
seven  years,  with  the  injections,  and  seeing  that  I would 
need  to  use  a large  number  of  them,  I desisted  on  account 
of  her  great  sensitiveness. 

The  Sex  deserves  some  consideration,  the  female  organ- 
ism requiring  less  than  the  male.  But  I have  frequently 
observed  elsewhere  as  here,  that  women  generally  withstand 
and  endure  the  pain  better  than  men.  Considering  men- 
struation and  pregnancy , and  the  effects  of  injections  as 
connected  therewith,  I will  describe  them  more  fully  in 
another  chapter.  I can  say  that  menstruation  is  not  at  all 


RESPECTING  SUBLIMATE  INJECTIONS. 


203 


a contraindication  for  the  subcutaneous  treatment,  since  the 
catamenia  are  neither  increased  nor  diminished  thereby. 
Neither  can  I say  that  the  hypodermic  medication  will 
either  induce,  or  augment  an  already  existing  irritability  of 
the  ovaries  and  uterus. 

Acute  Diseases,  which  happened  to  syphilitics — as,  for 
instance,  inflammation  of  the  respiratory,  circulatory  and 
digestive  organs,  exanthemic  fever,  &c. — are  always  a con- 
traindication for  the  injection.  Chronic  or  acute  diarrhoea, 
or  a disposition  towards  it,  must  be  taken  as  a contraindica- 
tion, or  at  least  the  utmost  care  and  judgment  are  necessary, 
if  the  hypodermic  medication  is  employed,  bearing  in  mind 
that  relatively  small  doses  of  sublimate  may  produce  here 
toxicological  effects — as  when  abnormally  large  doses  are 
taken  by  a healthy,  robust  individual. 

Acute  Articular  Rheumatism  is  not  a contraindica- 
tion. Several  observations  have  revealed  the  fact  that  the 
curative  effects  of  the  injection  were  as  favorable  in  rheu- 
matic as  in  syphilitic  ailments.  In  Case  No.  9 I have  men- 
tioned such  a result,  and  I have  treated  two  similar  cases 
with  the  same  good  results. 

In  cases  where  a dyscrasia  combines  syphilis  with  itself, 
it  is  necessary  to  make  a thorough  examination,  as  ought  to 
be  done  before  using  any  antisyphilitic  cure,  in  order  to 
ascertain  whether  the  dyscrasic  condition  appeared  before , 
simultaneously  or  after  the  manifestations  of  syphilis . This 
examination  requires  much  care,  because  it  is  well  known 
that  other  pathological  diseases  originate  from  different 
causes,  and  that  they  are  very  difficult  to  distinguish  from 
the  polymorphous  lues,  e.  g . syphilitic  adenitis,  resembling 
scrofulosis.  Anaemia,  chlorosis,  leucaemia  and  other  patho- 
logical changes  in  different  organs,  as  already  stated  in  the 


204 


RESPECTING  SUBLIMATE  INJECTIONS. 


chapters  on  visceral  syphilis,  give  but  little  margin  for  a 
differential  diagnosis  from  syphilitic  blood  alteration  and 
disease.  The  therapeutics  should  be  modified  according  to 
the  diagnosis.  Here  my  method  has  a great  advantage  over 
others,  since  I may  combine  with  it  any  other  treatment ; 
as,  for  instance,  in  a combination  of  scrofula  with  syphilis,  I 
may  use  at  the  same  time  iodide  of  potassium,  cod-liver  oil, 
&c. ; or,  with  anaemic  females,  I can  use  relatively  smaller 
doses  of  the  sublimate,  and  conjointly  give  internally  iron, 
&c. ; use  baths,  &c.  Concerning  the  disease  commonly 
called  tuberculosis , I have  but  three  cases  that  I shall 
report : 

Case  72. — Herman  B.,  a cigarmaker,  was  received  into  our  wards 
August  5th,  1868,  he  having  suffered  three  years  previously  from  a 
hard  chancre,  and  using  only  local  remedies  for  it.  Later,  spots  ap- 
peared upon  the  body  ; slight  scaling  off  of  the  epidermis  on  the  penis  ; 
pain  in  the  throat  also,  which  complaints  were  but  little  heeded  by 
the  patient,  and  therefore  they  received  no  treatment.  Two  years  sub* 
sequently  the  patient  was  attacked  with  inflammation  of  the  lungs,  in 
consequence  of  which  a cachectic  and  tuberculous  condition  was  de- 
veloped. During  the  last  six  months  he  has  had  ulcers  on  the  skin,  for 
which  he  used,  with  good  result,  mercurial  pills.  Patient  has  now  a 
cachectic  appearance  ; flabby  muscles  ; dull  eyes  ; stooping  gait ; a flat 
paralytic  thorax  ; but  little  adipose  tissue,  and  is  a complete  picture  of 
phthisis.  On  the  described  paralytic  thorax , near  the  fifth  and  sixth  right 
ribs , there  is  a flattened  depression.  Here  percussion  gives  the  11  cracked  pot” 
sound , and  auscultation  detects  mucous  rales.  . Of  syphilitic  appearances  we 
see  on  the  skin  a great  number  of  ulcers,  of  the  size  of  a penny,  covered 
partly  with  pyramidal  rupial  crusts  and  partly  with  dried  pus.  On  the 
scalp  the  ulcers  are  of  less  size,  but  reach  deeper  into  the  tissue.  The 
hair  is  but  sparsely  present.  The  erythema  of  the  fauces  and  the  ero- 
sions of  the  mucous  membrane  much  resemble  a stomatitis  produced  by 
mercury,  which  also  may  have  caused  the  swelling  of  the  mucous  mem- 
brane about  the  teeth. 

Notwithstanding  the  existence  of  vomicse  of  the  lungs,  we  did  not 
hesitate  to  use  the  sublimate  injections  with  the  patient,  and  began  the 


RESPECTING  SUBLIMATE  INJECTIONS. 


205 


same  August  5th  with  the  relatively  large  doses  of  \ gr.  We  were  soon 
compelled  to  pause  on  account  of  salivation,  and  when  we  resumed 
treatment  we  reduced  the  dose  to  J gr.  We  paused  but  once  again  (for 
four  days),  when  we  detected  blood  in  the  sputa.  After  using  3J  grs. 
of  sublimate,  we  had  the  pleasure  to  see  the  patient  rid  of  all  syphilitic 
affections.  During  the  whole  period  the  patient  felt  very  comfortable. 
Only  once  did  the  cough  increase,  on  account  of  taking  a cold,  but  it 
soon  assumed  its  normal  character.  The  appearance  of  the  patient  was 
improved,  and  his  weight,  which,  at  the  beginning  of  the  treatment, 
diminished  a trifle,  soon  increased  to  its  former  standard.  His  lung 
difficulty  remained  unaltered  by  the  cure. 


Although  I remarked,  page  41,  where  I treated  of  diet- 
etic rules  at  length,  that  inebriates  seemed  to  withstand  the 
injection  treatment  quite  well,  and  therefore  alcoholism  is  no 
contraindication , giving  Case  47  as  an  example, — I wish 
also  to  publish  here  a second  case,  in  which  the  patient, 
an  inebriate,  suffered  from  caries  that  might  have  been 
syphilitic. 

Case  73. — John  K.,  a laborer,  thirty-eight  years  old  ; from  a healthy 
family;  is,  according  to  his  own  testimony,  very  intemperate,  having 
been  already  twice  treated  in  our  hospital  for  delirium  tremens. 

His  first  syphilitic  infection  dates  back  to  the  year  1862.  It  vanished 
entirely,  except  leaving  a syphilitic  induration.  For  the  ulceration, 
and  also  for  the  later  arising  relapses,  in  the  form  of  exanthema,  he 
used  here  in  the  Charite  nothing  else  than  a botanic  treatment.  At 
the  time  of  admission,  the  patient  has  a crustaceous  exanthem,  which 
is  over  the  entire  body,  in  the  form  of  small  efflorescences ; also  psoriasis 
palmaris  and  plantaris.  Two  weeks  before,  the  patient  had  inflamma- 
tion of  the  joint  between  the  first  and  second  phalanges  of  the  little 
finger  on  the  left  hand,  which  was  excessively  painful.  Examination 
here  reveals  much  swelling,  and  crepitation  by  rubbing  the  second  and 
third  phalanxes  together. 

Although  the  patient  suffered  a week  prior  to  admission  into  our  wards  with 
delirium  tremens,  and  was  directly  transferred  from  the  so-called  A delirium 
room  ” I used  at  once  the  hypodermic  injections  of  sublimate , without  allowing 
him  any  alcoholic  drinks.  We  used  altogether  twenty  injections  of  J gr. 

18 


206 


QUANTITY  OF  SUBLIMATE  TO  BE  INJECTED. 


of  sublimate  each,  which  produced  the  disappearance  of  the  described 
exanthem,  while  the  disease  of  the  joint  did  not  increase  nor  materially 
abate. 


VII.— quantity  op  sublimate  to  be  injected. 

Having,  in  my  therapeutical  endeavors,  the  principal  aim 
to  find  a method  for  the  sure  and  quick  healing  of  syphilis, 
I have  not  restrained  myself,  in  my  experiments,  to  the 
trial  of  subcutaneous  injections  of  sublimate  alone,  but  have 
combined  it  also  either  with  the  internal  use  of  iodide  of 
potassium , or  with  a sarsaparilla  sweat-cure,  preceding  the 
injection  treatment  or  simultaneously  ivith  it.  Besides,  I 
have  given  some  patients  chlorate  of  potassa,  and  others, 
tannin,  in  order  to  prevent  the  troublesome  and  deleterious 
effects  of  salivation. 

For  each  of  these  combination  cures  a number  of  patients 
were  selected. 

The  following  tabulated  statement  is  the  best  proof  of  the 
results  obtained,  by  means  of  the  combined  methods,  in 
eight  hundred  cases  (six  hundred  being  women  and  two  hun- 
dred men).  These  eight  hundred  patients  are  the  material 
from  which  the  following  statistical  tables  are  arranged. 

I have  taken  only  these  eight  hundred  patients,  because 
their  treatment  commences  in  the  year  1865  and  continues 
to  the  end  of  1867,  thus  giving  me,  since  their  treatment, 
up  to  the  time  of  the  publication  of  this  work,  three  years, 
two  years  and  one  year,  respectively,  in  which  I have  had 
opportunity  to  observe  a greater  number  of  possible  relapses 
than  I possibly  could  have  had,  had  I tabulated  cases  treated 
since  1867. 


QUANTITY  OF  SUBLIMATE  TO  BE  INJECTED, 


207 


QUANTITY  OF  SUBLIMATE. 


WOMEN. 

MEN. 

CLASSES. 

Number 

of 

Cases. 

Total  of  Sublimate 

Injected. 

Average  Quantity- 

Injected. 

Number 

of 

Cases. 

Total  of  Sublimate 

Injected. 

Average  Quantity 

Injected. 

I.  Cases  in  which  subli- 
mate alone  was  injected, 
without  any  other  medi- 
cation   

134 

336} 

Grains. 

2} 

34 

103| 

Grains. 

3 

II.  Cases  where  the  sub- 
cutaneous injection  was 
preceded  by  a sarsapa- 
'rilla  sweat-cure  . . . 

58 

122J 

2* 

33 

70} 

2J 

III.  Cases  in  which  the  so 
called  hunger-cure  pre- 
ceded the  subcutaneous 
injection  method  . . 

33 

79} 

2§ 

IY.  Cases  in  which  the 
subcutaneous  injection 
was  used  simultaneously 
with  the  sarsaparilla 
sweat-cure 

24 

55} 

a* 

14 

33A 

2f 

Y.  Cases  in  which  iodide 
of  potassium  was  used 
internally,  in  addition 
to  the  subcutaneous  in- 
jection of  sublimate  . . 

90 

151f 

i} 

12 

27} 

2} 

YI.  Cases  in  which  the 
subcutaneous  injection 
was  used  with  internal 
use  of  chlorate  of  po- 
tassa  

185 

400} 

2} 

34 

86 

VII.  Cases  in  which  mor- 
phine was  used  with  the 
injected  fluid  and  tannin 
internally 

62 

116} 

1t9(T 

25 

41} 

if 

VIII.  Cases  in  which  the 
internal  use  of  iodide  of 
potassium  with  the  sub- 
cutaneous injection  was 
preceded  by  a sarsapa- 
rilla sweat-cure  . . . 

34 

50} 

i} 

208 


QUANTITY  OF  SUBLIMATE  TO  BE  INJECTED. 


QUANTITY  OF  SUBLIMATE — continued. 


WOMEN. 

MEN. 

CLASSES. 

Number 

of 

Cases. 

Total  of  Sublimate 

Injected. 

Average  Quantity 

Injected. 

Number 

of 

Cases. 

Total  of  Sublimate 

Injected. 

Average  Quantity 

Injected. 

IX.  Cases  where  the  in- 
ternal use  of  chlorate 
of  potassa,  with  subli- 
mate injection,  was  pre- 
ceded by  a sarsaparilla 
sweat-cure 

13 

28J 

Grains. 

21 

5 

101 

Grains. 

2?V 

X.  Cases  in  which  the  use 
of  iodide  of  potassium, 
with  injection  of  subli- 
mate, was  preceded  by 
the  so  called  hunger- 
cure  

10 

161 

It 

Total 

600 

1272 

21 

200 

4681 

21 

The  quantity  of  the  injected  sublimate  with  two  hundred 
male  patients  was  468J  grs.,  or  for  each  patient  m g^., 
or  about  2J  grs.  of  sublimate  was  used,  by  which  the  visible 
symptoms  of  syphilis  were  destroyed. 

The  quantity  of  sublimate  given  to  six  hundred  female 
patients  was  1272  grs.,  or  for  each  patient  253g  grs.,  or 
about  2^  grs.  of  sublimate. 

This  difference  of  it  gr.  about  \ gr.  (equal  to  two  syringes 
full  of  the  solution  No.  2)  in  favor  of  the  female  patient,  is 
augmented  from  £ gr.  to  J gr.,  when  we  consider  the  re- 
latively great  quantities  of  sublimate,  which  was  necessary 
for  some  female  patients,  on  account  of  their  very  extensive 
and  very  obstinate  syphilitic  formations. 


QUANTITY  OF  SUBLIMATE  TO  BE  INJECTED. 


209 


The  therapeutical  result  varies  in  the  different  classes , ar- 
ranged according  to  the  different  combination  cures  employed. 
Here,  however,  we  should  naturally  consider  the  greatness  or 
smallness  of  the  treated  affection  to  fully  judge  of  the  produced 
effect.  A glance  at  the  tables  shows  the  average  quantity 
necessary  for  a cure  ranges  between  the  amount  of  3 grs.  and 
1}  gr.  We  see  further  that,  patients  of  the  first  class,  i.  e.y 
such  as  were  treated  with  the  subcutaneous  injections  alone, 
needed  a larger  quantity  of  sublimate  to  effect  a cure,  the 
female  patients  receiving  2J  grs.,  and  the  male  3 grs. 

By  the  remaining  eight  classes,  females  as  well  as  males, 
the  quantity  of  injected  sublimate  is  somewhat  reduced  in 
those  patients  who  had  previously  to  the  injection  undergone 
a sarsaparilla  sweat-cure.  Although  these  same  patients,  as 
we  will  show  further  on,  had  somewThat  fewer  relapses,  this 
advantage,  together  with  the  small  fractional  amount  of  sub- 
limate saved,  is  so  insignificant,  that  it  would  be  more  than 
irrational  to  subject  a patient,  before  using  our  sublimate 
injection  method,  to  that  cure  which  takes  about  four  weeks. 
Aside  from  its  costliness,  and  the  length  of  time  necessary, 
it  rather  weakens  the  patient  and  subjects  him  to  colds,  as 
we  have  had  occasion  to  notice. 

The  class  in  question  contained,  to  a large  extent,  patients 
who  suffered  but  slightly  with  syphilis,  or  with  the  affection 
of  that  type  which  was  readily  amenable  to  treatment. 

The  most  favorable  results  we  see  in  those  patients  who 
used  either  iodide  of  potassium , or  tannin  in  conjunction 
with  the  hypodermic  medication , (classes  v.,  vii.  andix.)  The 
latter  had  the  addition  of  morphia  to  the  sublimate.  But  as 
iodide  of  potassium  augmented  the  disposition  to  salivation, 
and  the  inclination  to  relapses,  and  as  tannin  may  produce 
disturbances  in  the  digestive  apparatus,  their  advantages  are 

18* 


210 


RELAPSES  OF  SYPHILIS. 


balanced  by  their  disadvantages,  and,  therefore,  the  final  con- 
clusion is  that,  with  the  simple  subcutaneous  injection  neither 
another  cure  ought  to  precede  nor  be  combined  with  it , but  for 
lessening  pain  and  relapse,  small  doses  of  morphia  may  be 
added  to  the  sublimate. 

YIIL— RELAPSES  OF  SYPHILIS. 

“ Relapses  occurring  after  every  treatment,  are  not  the 
exception , but  the  rule . Yes,  for  a century,  investigation 
has  been  going  on,  and  in  recent  times,  as  in  the  times  of 
Ulrich  von  Huttens,  the  frequency  of  relapses  is  the  worst 
curse  appertaining  to  this  disease.” 

This  saying  of  Yon  Bmrensprung,  is  almost  identical  with 
the  assertions  of  French  syphilographs,  and  stands  as  a fixed 
law  concerning  the  frequency  of  relapses,  (la  loi  des  recidives) 
which  is  not  only  a constant  threat  for  the  layman,  filling 
him  with  gloomy  forebodings  of  the  future,  but  is  the  great 
complaint  of  the  physician,  and  robs  him  of  the  satisfaction 
he  might  feel  in  the  accomplished  cure. 

To  solve  the  question  how  the  number  of  relapses  occur- 
ring with  my  treatment,  compares  with  other  antisyphilitic 
treatments,  a statistical  basis  is  particularly  demanded.  But 
to  obtain  statistics  in  this  particular  branch  of  medicine, 
syphilis,  is  not  very  easy.  The  great  difficulty  arises  from 
the  fact,  that  the  largest  number  of  patients  who  suffer  from 
a syphilitic  relapse,  condemn  the  formerly  received  medical 
treatment  and  go  to  other  doctors,  hoping  thereby  to  get 
radically  cured.  There  are  certain  classes  of  persons  who 
are  obliged  to  undergo  in  sickness  a special  treatment  in 
hospitals  set  apart  for  them,  I mean  those  persons  under 
police  surveillance,  the  puellae  publics,  and  soldiers;  but  even 


RELAPSES  OF  SYPHILIS. 


211 


here  circumstances  happen  which  make  the  gathering  of 
statistics  difficult  or  even  impossible. 

As  to  the  mentioned  prostitutes,  they  know  only  too  well 
how  to  evade  a police  control;  and  in  the  larger  cities,  with 
the  exception  of  Berlin,  there  are  more  syphilitic  hospitals 
than  one  where  the  patients  have  their  choice — indulging 
very  readily  in  the  tempting  principle  of  change. 

Concerning  soldiers  who  are  obliged  to  undergo  treatment 
in  military  hospitals,  their  time  of  service  is  too  short  to  give 
clear  and  sufficient  observations  for  studying  syphilitic  re- 
lapses. 

The  first  statistical  resources  that  we  find  in  our  medical 
literature  have  already  these  shortcomings.  They  are  the 
published  records  of  French  military  surgeons  of  the  begin- 
ning of  the  present  century,  as  Devergie,  Barthelemie,  Des- 
ruelles,  &c.,  about  relapses  occurring  with  mercurial  or  anti- 
mercurial treatment  in  soldiers  treated  by  them.  But  the 
soldier  remains  only  two  years  in  Paris  in  garrison.  There 
is  another  momentum  to  be  considered,  which  further  dam- 
ages the  value  of  their  statistics.  The  authors  were  earnest 
adherents  to  Broussais ’ Inflammatory  Theory , taking  lues 
for  an  inflammatory  process,  as  they  did  every  manner  of 
genesis  and  duration  of  the  disease.  They  stated  no  dis- 
tinction between  a primary  and  a well  marked  constitutional 
syphilis,  and  as  a consequence  they  had  really  syphilitic  re- 
lapses equally  divided  for  patients  of  every  description. 
Among  the  6000  patients  whose  cases  were  tabulated  by 
Devergie  for  proving  his  assertion  of  the  favorable  circum- 
stances resulting  from  the  antisyphilitic  treatment,  there  are, 
in  point  of  fact,  nearly  5000  who  were  affected  only  with 
gonorrhoea,  epididymitis,  acuminata,  &c.,  in  whom  relapses, 
in  one  sense,  are  not  to  be  mentioned.  By  reduction  of  the 


212 


RELAPSES  OE  SYPHILIS. 


patients  from  6000  to  1000,  the  percentage  of  Devergie’s 
relapses  will  rise  from  7 per  cent,  to  35  per  cent.  But  even 
this  high  number  is  not  yet  free  from  error,  because  those 
syphilographs,  the  images  of  our  present  anti-mercurialists, 
combated,  in  abstractor  against  the  use  of  mercury,  but  never- 
theless, not  only  used  it  in  such  cases,  as  we  to-day  see  an 
indication  for  its  use,  for  instance,  “if,  during  the  simple 
treatment,  red  spots,  papules  or  pustules  appear,”  but  even 
they  employed  it  in  local  affections  which  “have. arisen  after 
a very  short  state  of  incubation,”  or  “which  have  withstood 
other  local  treatment  for  quite  a time.”  (Desruelles.) 

The  same  error  we  find  in  the  statistical  references  of  the 
English  physicians.  All  through,  like  a red  thread,  we  find 
the  mistake  between  primary  and  secondary  syphilis.  We 
find  always  the  contradiction  of  charging  mercury  to  be  the 
cause  of  “the  malignant  course  of  syphilis  and  relapses,” 
and  after  all  proclaiming  it  as  the  ultimum  refugium  for  the 
malignant  forms. 

But  how  far  a partisan  predilection  and  one-sidedness  may 
bring  about  real  drastic  delusions,  we  see  in  the  well  known 
statement  of  Fergusson’s,  during  his  stay  in  Spain  and  Portu- 
gal, which  paints  up  the  result  of  the  non-mercurial  treat- 
ment in  a very  rose-colored  way,  so  that  it  has  caused  the 
quick-spreading  of  the  so-called  “simple  treatment.”  But 
even  now  the  small  remaining  number  of  Furgusson’s  ad- 
mirers do  not  yet  see  that  he  not  only  observed  very  super- 
ficially, but  also  that  his  assertions  were  in  complete  contra- 
diction with  his  own  English  colleagues  serving  in  Spain,  as 
well  as  with  the  native  Spanish  physicians. 

Concerning  the  statements  of  other  English  physicians 
serving  in  the  army , they,  too,  are  not  of  any  real  value. 
This  is  the  case  with  the  official  statement  of  Thom.  Clarke, 


RELAPSES  OF  SYPHILIS. 


213 


about  338  patients  treated  by  him,  during  the  years  1829  to 
1832,  of  whom  only  46  persons  suffered  with  real  syphilis ; 
so  also  with  other  pamphlets  published  by  Gregor  & W. 
Franklin. 

But  we  must  recognise,  too,  that  English  surgeons  sooner 
abondoned  the  anti-mercurial  treatment  than  the  continental 
physicians.  The  discussion  of  the  Medical  Society  of  London, 
on  the  9th  December,  1839,  is  indicative  of  this  change  of 
opinion.  Dendy,  one  of  the  warmest  defenders  of  a dietetic 
treatment,  asserts  that  he  has  arrived  at  the  conclusion  that 
mercury  is  the  surest  remedy  for  the  healing  of  syphilis,  and 
against  relapses, — an  assertion  which  was  accepted  by  all 
medical  authorities  of  that  time,  without  much  opposition. 

As  to  other  countries  on  the  continent,  the  Swedish  sur- 
geons give  the  most  minute  details  in  reference  to  relapses 
after  different  antisyphilitic  remedies.  The  Royal  Sanitary 
Commission  tables  comprise  46,687  cases.  But  even  here 
we  miss  the  distinction  between  local  and  syphilitic  affections, 
and  therefore,  those  published  tables  where,  after  a non- 
mercurial treatment  only,  16  per  cent,  of  relapses  occurred, 
are  of  no  value  whatever,  and  we  meet  here  at  the  same  time, 
the  curious  final  assertion  that  in  a great  number  of  cases, 
mercury  was  equally  useful  and  important. 

Of  Italian  surgeons , only  Calderini,  hospital  surgeon  at 
Milan,  has  published  a statistical  work  based  on  cases 
treated  there.  There  were  1050  patients,  of  whom  524  were 
treated  with  mercury,  and  526  according  to  the  antisyphilitic 
method. 

As  we  have  seen,  in  all  these  statements  there  is  no  reli- 
ance, and  even  our  most  recent  investigations  have  either 
given  very  scant  statistical  tables,  or  they  have  been  actuated 
by  a partisan  spirit.  This  is  particularly  the  case  with  Her- 


214 


RELAPSES  OF  SYPHILIS. 


mann,  of  Vienna,  so  that  his  assertions  cannot  claim  a scien- 
tific consideration.  In  the  beginning  of  his  work,  entitled, 
“The  Mercurial  Diseases,”  (Vienna,  1865,)  we  find  the  fol- 
lowing curious  statement : 

“ Of  the  whole  number  of  patients  treated  in  the  years 
from  1856  to  1864,  amounting  to  7796  patients,  there  came 
during  a period  of  six  years  335  persons  twice,  70  persons 
three  times,  30  persons  four  times,  8 persons  five  times,  and 
3 persons  six  times  to  our  hospital.  In  all  these  cases  fresh 
infections  took  place , and  in  none  was  there  a real  relapse , or 
a higher  degree  of  development  of  the  existing  forms  of  syphi- 
lis” 

Diday,*  who  advocated  a modified  mercurial  treatment, 
and  an  expectant  kind,  is  rather  small  concerning  statistics, 
but  after  all  has  a certain  significance : 

“ Of  43  patients  accurately  watched  and  expectantly 
treated,  3 patients,  7 per  cent,  did  not  relapse ; 40  patients, 
93  per  cent,  did  relapse,  to  whom  there  occurred  two  re- 
lapses to  17  patients,  three  relapses  to  12  patients,  four  re- 
lapses to  4 patients,  and  seven  relapses  to  6 patients.  With 
these  relapsing  patients  syphilis  ran  in  a mild  form  in  23 
cases,  57.5  per  cent. ; in  a severe  form  in  17  cases,  42.5  per 
cent. ; in  a tertiary  form  in  4 cases,  4 per  cent.  So  that 
finally  as  an  ultima  ratio,  mercury  was  taken;  il  avait  finale- 
men  t fallu  y avoir  recours.” 

Yvaren’sf  statistical  material  comprises  150  relapses  in 
the  form  of  inveterately  severe  lues,  35  cases  were  treated 
without  mercury;  in  31  cases  mercury  was  given  irregularly 

* Historie  Naturelle  de  la  Syphilis.  Paris,  1863,  p.  138. 

| Yvafen,  Traite  sur  les  Metamorphoses  de  la  Syphilis,  Paris,  1854 ; 
Kussmaul,  p.  24  ; Bazin,  p.  130. 


RELAPSES  OE  SYPHILIS. 


215 


and  insufficiently;  in  17  cases  it  was  given  in  appropriate 
doses. 

But  how  little  mercury  was  the  cause  of  the  severity  of 
the  lues  was  clearly  shown  by  the  fact  that,  by  the  repeated 
use  of  mercury  80  patients  of  the  above  number  were  com- 
pletely cured. 

A further  proof  that  mercury  does  not  cause  relapses  in 
syphilis  we  find  by  the  well  known  Danish  author,  En- 
gelstedt.  He  says  that  the  severest  and  the  most  obstinate  re- 
lapses occur  only  in  persons  in  whom  the  primary  constitu- 
tional symptoms,  light  in  themselves,  were  not  treated  with 
an  energetic,  especially  a mercurial  medication,  “ and  the 
disuse  of  mercury  favors  the  relapses  of  syphilis .”  In  the 
translation  of  Uterhardt,*  numbers  are  rather  uncertain  in 
their  expression  of  percentage  of  both  the  relapses,  and  the 
absolute  cures,  and  therefore  valueless.  He  says  relapses 
occurred,  after  using  sublimate,  55  times;  after  using  calo- 
mel, 35  times;  after  using  inunction  cure,  4 times,  and  after 
using  an  undescribed  mercurial  preparation,  20  times. 

A work  which,  by  its  great  exterior,  captivates  for  the 
first  moment,  but  by  a more  careful  perusal  loses  its  signi- 
ficance for  our  purpose,  is  that  one  written  with  so  great 
diligence,  viz.:  “Recherches  sur  la  Syphilis  appuj^es  de 
tableaux  de  statistique  tir£s  des  archives  des  hopitaux  de 
Christiania,  par  W.  Boeck.”  But  those  3000  cases  were 
written  in  a time  when  an  exact  observation  according  to 
the  present  state  of  science  was  impossible.  The  Norwegian 
author  has,  in  publishing  his  work,  the  object  to  popularize 
the  excellency  of  his  method,  “syphilization,”  as  may  be  seen 
by  the  following  table,  which  one  of  the  most  enthusiastic 

* Hie  Constitutionellc  Syphilis  nacli  klinischen  Untersucliungen. 
Uebersetzt  von  C.  Uterhardt,  Wurzburg,  1861. 


216 


RELAPSES  OF  SYPHILIS. 


admirer-s  of  the  method,  Auzias  Turenne,  has  published  in 
his  “Recueil  des  travaux  de  la  -Society  medicale  allemande 
de  Paris,”  (1865): 


& 

o 

i — i 

EH 
< 
I— I 

3 

P-l 

t* 

U1 


Therapeutics. 

Number 

of 

Cases. 

Average 

duration. 

Relapses. 

Deaths. 

Number 

of 

Cases. 

Percentage. 

Number 

of 

Cases. 

Percentage. 

days. 

Mercury 

3200 

125 

1036 

32 

108 

Q3 

(32.375) 

Iodide  of  Potas’m 

186 

108 

40 

21 

2 

1 

(21.5) 

' Without  the  pre- 

) 

ceding  use  of 

V252 

134 

23 

H 

mercury 

J 

(9.127) 

In  relapses  after 

\ 54 

191 

10 

18  J 

using  mercury 

/ 

(18.33) 

Without  result 

I 

after  using  mer- 

r  6 

347 

2 

33* 

cury 

J 

(33.33) 

Tartarization 

157 

178 

31 

20 

(19.745) 

Syphilization  is,  according  to  its  author  in  regard  to  re- 
lapses, almost  a preventive,  but  the  contradiction  of  it  is 
apparent  when  we  read  Turenne’s  assertion,  “En  outre  de 
cette  maniere  les  chances  de  r^cedive  sont  reduites  a presque 
rien  ; car  dans  les  trois  dernieres  ann£es  pendant  lesquelles 
M.  Boeck  s’est  born£  a l’inoculation  de  la  matierede  chancres 
indures,  iln’a  pas  mentionne  une  seule  recidive  tandis  que 
dans  sept  ou  huit  annees  precedentes  . . . . le  nombre  des 
recidives  montait  &neuf  et  demi  pour  100,”  and  more  so 
when  we  compare  it  with  other  reliable  authors.  But  Boeck, 


KELAPSES  OF  SYPHILIS. 


217 


in  a conversation  with  Lancereaux  (Traite  histor.  et  prat  de 
la  Syphilis,  Paris,  1866,  p.  749),  says  that  the  number  of 
relapses  are  about  twelve  or  thirteen  per  cent.,  and  that  ac- 
cords with  Boeck’s  own  statement  in  the  year  1860  : “De 
la  Syphilisation  etat  actuel  et  statistique.’, 

A.  Oewre  (Med.  Times  and  Gazette,  1868,  p.  929),*  bases 
his  assertion  that  syphilization  exerts  no  influence  over 
syphilis,  chiefly  on  the  fact  of  so  frequent  relapses  of  syphilis. 

In  recent  times  Depres  has  spoken  emphatically  against 
the  use  of  mercury  in  the  discussions  of  the  Societe  Im- 
perial de  Chirugie  at  Paris,  in  1867,  and  imputed  to  mer- 
cury the  most  obstinate  and  frequent  relapses.  Full  of  zeal 
for  statistical  arguments  against  this  drug,  he  undertook 
several  raids  upon  the  different  hospitals  of  Paris,  but  neither 
in  the  “ Hospital  de  Lourcine,”  nor  “ Hospital  de  St.  Louis,” 
could  he  find  any  statistical  proof.  His  travels  were  a piti- 
able odyssey.  Against  his  own  statistical  observations  which 
he  made,  during  eighteen  months  at  the  “ Lourcine, ” im- 
portant objections  were  made.  The  statistics  he  made  at 
Hillairet’s  wards  in  the  “ St.  Louis  Hospital,”  were  disavowed 
by  Hillairet  himself.  As  to  the  conclusions  which  Desprds 
drew  from  two  hundred  and  forty-seven  cases  observed, 
which  observations  he  received  from  Laillier,  chief  surgeon 
at  the  “ St.  Louis  Hospital,”  the  latter  wrote  a letter  to 
Blot,  in  which  he  denies  all  responsibility. 

As  conclusively  shown,  there  is  an  evident  lack  of  reliable 
statistical  references,  and  therefore  I am  obliged  to  get 
comparative  starting  points  for  my  method,  procuring  the 
material  in  my  own  way.  For  this  end  I have  used  the 
extensive  material  of  the  “ Registration  of  the  Berlin 

* Archiv  fur  Dermatologic  und  Syphilis  von  Auspitz  und  Pick,  18G9, 
1 Jahrg,  1 Hft.  S.  135. 

19 


218 


RELAPSES  OF  SYPHILIS. 


Charity”  in  which  the  history  of  all  cases  for  the  last 
twenty  years  is  fully  preserved.  From  out  of  this  abun- 
dance I have  selected  only  two  thousand  suitable  cases, 
which  I have  rearranged  in  tabular  form,  showing  the  affec- 
tions, the  instituted  treatment  and  the  intervals  between  the 
single  relapses. 

With  such  a clear  pathological  curriculum  vitae  of  two 
thousand  patients,  I could  follow  syphilis  from  its  very 
incipiency  to  its  later  stages  of  development — from  the 
sclerosis  on  the  genitals  to  the  final  phases  of  visceral 
syphilis  and  forms  producing  a fatal  issue.  I have  only 
taken  female  patients  for  my  statistical  material,  because 
the  male  patients  are  free  from  all  police  surveillance,  and 
therefore  could  not  be  as  reliable  as  to  estimating  the  pro- 
portion of  relapses. 

By  a closer  examination  of  this  female  material,  I found 
some  errors ; as,  for  instance,  a lack  of  precision  in  diag- 
nosis and  therapeutics,  as  recorded ; so  that,  with  the  cases 
where  care  was  taken,  I could  use  only  1420  patients  for 
the  purpose  of  my  statistics.  One-half  used  the  sarsaparilla 
sweat-cure .* 

The  statistical  results  from  this  treatment,  in  reference  to 
relapses  of  syphilis,  are  as  follows  : 

Of  the  710  patients  who  have  used  a sarsaparilla  sweat- 
cure,  456  women,  or  64.22  per  cent.,  had  relapses  of 

* Von  Baerensprung  used  generally  a decoction  of 
R.  Rad.  sarsaparillae ; 

Spec,  ad  decoct,  ligni,  aa  5ii  5 
Rad.  caricis,  5SS5 
Fol.  sennae,  gj ; 

Aqua  distill,  lb.j. 

After  using  this  decoction,  the  patient  must  remain,  in  the  morning, 
wrapped  in  woollen  blankets,  and  sweat  for  one  or  two  hours. 


RELAPSES  OF  SYPHILIS. 


219 


syphilis — occurring  once  in  260  patients,  or  36.62  per 
cent. ; twice  in  81  patients,  or  11.4  per  cent. ; three  or 
more  times  in  115  patients,  or  16.19  per  cent. 

Patients  who  were  treated  with  mercurial  preparations,* 
there  occurred,  in  710  patients,  relapses  with  464  persons, 
or  65.35  per  cent. ; once  in  203  patients,  or  28.6  per  cent. ; 
twice  in  116  patients,  or  16.34  per  cent. ; three  or  more 
times  in  145  patients,  or  20.42  per  cent. 

According  to  this  we  perceive  that,  after  a mercurial  and 
a botanic  treatment,  the  relapses  are  almost  equal,  i.  e.  on 
an  average  of  about  65  per  cent. 

This  number,  high  as  it  is,  may  not,  after  all,  give  the 
right  proportion.  Among  these  1420  patients,  nearly  350 
were  women  who  came  of  their  own  accord , without  any 
interposition  of  the  police,  to  the  Charity.  They  were  partly 
servants  and  partly  married  women.  Of  this  number  only 
50  persons,  or  14J  per  cent.,  returned,  on  account  of  a 
recurring  sickness,  into  the  Charite ; so  that  the  remainder, 
if  they  had  a relapse,  probably  sought  relief  outside  of  the 
hospital. 

Deducting  these  350  women,  and  we  see  that  in  1070 
patients,  870,  or  81.3  per  cent.,  wTere  taken  with  relapses. 
But  if  we  consider  that  even  surgical  surveillance  may  over- 

* The  preparations  of  mercury  were  different.  We  mostly  used  it 
internally,  as  hydrargyrum  iodat.  flav.  (Simon,  V.  Baerensprung) ; hy- 
drargyr.  chlor.  mite  (Simon)  ; hydrargyr.  bichlorat.  corrosiv.  (V.  Bae- 
rensprung)  ; hydrarg.  albuminat.  (V.  Baerensprung) ; unguent,  hydrarg. 
cinererum.  The  ratio,  as  given,  are  about  as  follows: 

Hydrargy.  iodat.  flav.  to  of  the  cases  ; 

11  bichlorat.  corrosiv.  to  A of  the  cases ; 

11  chlorat.  mite  to  of  the  cases  ; 

“ albuminat.  to  ^ of  the  cases  ; 

Inunction  cure  to  ^ of  the  cases. 


220 


RELAPSES  OF  SYPHILIS. 


look  certain  syphilitic  affections,  e . g . small  hidden  plaques 
muqueuses  on  the  pharynx,  or  some  syphiloid  may  not  be 
recognised ; and  again,  some  prostitutes  evade,  for  a longer 
or  shorter  time,  police  surveillance  by  sharp  practice.  We 
do  not  think  the  figures  too  high,  when  we  fix  the  percentage 
of  relapses  from  81  to  90  per  cent. 

The  small  difference  of  1.4  per  cent,  in  favor  of  the 
botanic  treatment  is  more  than  overbalanced  when  we  con- 
sider the  circumstance  that  the  latter  treatment  has  been  in 
vogue  only  since  the  year  1858 ; so  that  all  the  relapses 
following  this  treatment  could  not  have  taken  place  in  the 
relatively  short  period  of  five  years. 

But  patients  treated,  between  the  years  1845  and  1858, 
with  mercury,  we  can  assume  with  certainty  that  with  them 
the  syphilis  is  entirely  eradicated. 

The  numerical  proportion  of  the  patients  who  not  only 
once,  but  several  times  have  been  attacked  with  syphilis,  is 
the  following : 

Of  456  persons  who  have  been  treated  with  mercury,  1010 
relapses  have  to  be  divided,  so  that  two  relapses  occur  to 
each  individual.  Of  430  persons  who  have  been  treated 
botanically,  only  859  relapses  take  place ; so  that  here  there 
are  two  relapses  for  every  patient. 

A second  important  question  is,  in  what  length  of  time  do 
relapses  appear  after  a botanic  and  after  a mercurial  cure  ? 
This  examination  is,  aside  from  its  absolute  value,  in  refer- 
ence to  the  relatively  high  value  of  each. 

We  commenced  our  injection  treatment  already  in  the 
year  1865,  but  we  treated  then  only  41  persons.  The 
remaining  560  patients,  who  are  counted  in  the  relapses,  we 
used  this  treatment  upon  in  the  following  years,  1866  and 
1867.  But  as  in  the  expired  time  of  respectively  four,  three 


RELAPSES 


I. 


II. 


Patients  who  received  only 
sublimate  injections. 


Patients  with  the  subl 
mate  injection  and  sa 
8aparilla  sweat-cure. 


Total. 


When  received. 


No.  of  patients. 

No.  under  police 
surveillance. 

No.  of  relapses. 

Percentage. 

No.  of  patients. 

No.  under  police 
surveillance. 

No.  of  relapses. 

Percentage. 

6 

) 

l 

C 

No.  of  relapses. 

Percentage. 

A. 

From  Oct.  1st,  1865,  to 

June  30th,  1866, 

19 

15 

7 

46f 

22 

18 

9 

51 

3 

16 

48J 

(8*) 

(53*) 

(10) 

(55 

(17) 

(54) 

From  July  1st  to  Dec. 

31st,  1866, 

88 

71 

24 

33| 

36 

29 

12 

41 

2 

46 

38 

(27) 

(38) 

(13) 

(45 

(53) 

(43) 

From  Jan.  1st  to  June 

30th,  1867, 

0 

62 

36£ 

(75) 

(44) 

From  July  1st  to  Dec. 

31st,  1867, 

27 

23 

10 

43J 

. . 

9 

48 

304 

(12) 

(52) 

’ 

(75) 

(47) 

Total, 

134 

109 

41 

33 

58 

47 

21 

44 

4 

172 

351 

(47) 

(43) 

(23) 

(49 

(220) 

(45) 

* Of  the  nun 


RELAPSES  OF  SYPHILIS. 


221 


and  two  years  not  all  the  relapses  have  yet  occurred,  we 
have  been  compelled  to  estimate  those  which  might  occur. 

For  this  end  we  selected  cases  from  all  the  “ sick  jour- 
nals” of  the  Royal  Charite,  in  which  the  most  accurate 
observations  upon  occurring  relapses  are  stated.  Of  these 
patients,  456  persons  were  treated  in  the  years  from  1846 
to  1858  with  a mercurial  medication,  and  404  persons  from 
1858  to  1863  with  the  sarsaparilla  sweat-cure. 

An  exact  tabular  statement  of  the  ascertained  result  I 
have  published  in  my  former  work  (Charity  Annals,  Yol. 
XIV.,  p.  556). 

The  780  relapses  occurring  after  botanic  treatment  were 
divided  into  eight  different  numerical  groups , according  to 
the  state  of  the  patient  between  the  first  treatment  and  the 
first  relapse,  or  between  the  first  and  second  relapse,  or 
between  the  second  and  third  relapse,  &c.,  up  to  the  eighth. 

The  other  1010  relapses , which  occurred  many  years  ago , 
and  on  account  of  the  instituted  mercurial  treatment , have  to 
be  classed  into  ten  numerical  groups , since  many  of  the  pa- 
tients had  eight , nine  or  ten  relapses.  See  Table  of  Re- 
lapses. 

For  a precise  calculation  of  the  intervals  occurring  be- 
tween the  single  groups  of  relapses,  the  already  mentioned 
classes  were  divided  into  fifteen  subdivisions. 

The  results  which  are  interesting  are  the  following : 

1.  The  by  far  greater  number  of  relapses  appeared  during 
the  first  year  after  all  antisyphilitic  cures,  and  especially 
after  the  botanic  treatment,  in  the  proportion  of  91  per 
cent. ; mercurial,  83  per  cent.  Of  11  remaining  classes, 
respectively,  17  per  cent,  of  relapses  occurred  during  the 
second  year.  Still,  after  a mercurial  treatment,  there  is  yet 

19* 


222 


RELAPSES  OF  SYPHILIS. 


seven  per  cent.  ; after  a botanic  treatment,  twelve  per  cent. 
The  two  yet  remaining  classes,  respectively,  develop  five  per 
cent,  of  relapses  during  intervals  of  many  years.  According 
to  analogies  as  to  these  ascertained  results,  we  calculated 
what  percentage  of  relapses,  after  our  subcutaneous  injec- 
tions of  sublimate,  had  occurred  till  now,  and  what  and  how 
many  would  probably  occur. 

In  the  foregoing  table  on  relapses  we  show  all  the  relapses 
occurring  till  the  year  1867,  together  with  the  probable  total 
of  the  yet  occurring  relapses.  To  show  the  result  of  the 
combined  treatment,  we  also  gave  a table.  The  result  as 
there  exhibited,  where  even  the  most  unfavorable  chances  for 
our  cure  have  been  given  full  consideration,  is  that  with  a 
high  probability,  the  number  of  relapses  following  the  subcu- 
taneous sublimate  injection  is , at  the  highest  estimate , but  45 
per  cent .,  or  85  per  cent . less  than  with  a treatment  either 
mercurial  or  botanic. 

We  separate  in  this  manner  & progressive  from  a regressive 
syphilis.  The  latter  is  always  of  a milder  character  and 
lighter  form,  as,  for  instance,  the  more  or  less  eroded  broad 
condylomes  on  the  genitals,  erosions  of  the  mucous  mem- 
brane of  the  pharynx,  superficial  disturbances  of  the  skin, 
especially  erythematous  and  maculous  exanthema,  and  the 
moderate  loss  of  hair.  But  the  progressive  kind  to  syphilis 
always  takes  a deeper  hold  of  the  tissues.  The  broad  condy- 
lomes do  not  only  show  superficial  erosions,  but  also  deep 
ulceration.  Papulous  and  squamous  infiltration  attack  the 
skin,  and  sometimes  gummous  iritis  develops.  But  as  the 
farthest  progressed,  besides  visceral  syphilis,  we  must  desig- 
nate those  external  progresses  in  which  new  formations  of  a 
gummous  nature  arise,  and  the  infiltrations  show  already  a 
tendency  to  an  ulcerative  destruction.  In  this  category  we 
class  the  pustulous  efflorescences  as  occurring  in  the  form  of 


RELAPSES  OF  SYPHILIS. 


223 


ecthyma,  and  rupia ; lupus  and  deeper  diseases  of  the  bones, 
parenchymatous  astitis,  gummous  orchitis,  and  affections 
with  which,  not  very  rarely,  destructive  ulcerations  of  the 
pharynx  and  larynx  exist. 

Which  character  the  relapses,  after  our  subcutaneous  in- 
jection have  shown,  whether  they  have  assumed  the  character 
of  progressive  or  regressive  syphilis,  must  be  solved  by  the 
import  of  our  registered  material. 

These  records  of  the  ailments  of  such  females  as  have  been 
visited  by  the  severest  forms  of  syphilis,  particularly  the 
tertiary , are  of  considerable  importance.  From  their  thera- 
peutical anamnesia,  I hoped  to  give  some  valuable  confirm- 
ations of  my  object.  But  my  efforts  have  been  crowned  only 
with  poor  success.  The  registered  records  of  such  patients 
were  in  surprisingly  small  numbers,  only  39  being  present. 
These  were  very  incomplete,  and  very  often  for  fixing  the 
more  important  anamnestic  and  therapeutical  points,  the 
necessary  numbers  of  the  record  were  wanting.*  This  was 

* Yon  Baerensprung,  says,  (Annals  of  the  Charite,  vol.  ix.,  1860,  p.  191,) 
li  if  I overlook  the  150  cases  of  inveterate  syphilis  which  developed  into 
tertiary  formations,  whose  history  I have  gathered,  I find  among  them 
122  in  which  the  patient  was  repeatedly  treated  with  mercury;  in  four 
cases  nothing  could  be  definitely  made  out  from  the  anamnesia ; only 
four  cases  are  among  them  in  which  we  could  assume  with  any  degree 
of  certainty  that  no  mercury  at  all  was  used.” 

These  122  cases  Yon  Baerensprung  has  probably  gathered  in*  his  pri- 
vate papers.  I did  not  find  them  among  the  documents  of  the  Regis- 
trar’s office  ; on  the  contrary,  the  number  of  female  patients  in  whom  no 
mercurial  treatment  could  be  made  out,  I find  to  be  already  greater  than 
given  by  Yon  Baerensprung.  In  the  report  of  the  physicians  of  the  Im- 
perial Royal  Hospital  at  Yienna,  of  the  year  1867,  we  read  on  the  con- 
trary, as  follows:  u Diseases  of  the  bone  were  observed  in  cases  of 
secondary  syphilis  fourteen  times  in  men,  and  twice  in  women,  among 
703  patients,  of  whom  only  four  men  had  gone  through  a mercurial 
treatment,  the  remainder  being  treated  only  locally.” 


224 


RELAPSES  OF  SYPHILIS. 


particularly  the  case  with  such  persons  as  never  underwent 
a treatment  with  mercury,  hence  I am  justifiable  in  making 
assumptions  according  to  minute  examinations  and  researches. 

These  records  of  the  39  sick,  which  I found  in  the  Regis- 
trar’s office,  cannot  all  be  classed  as  clear  cases,  because  the 
treatment  was  partly  mercurial  and  partly  botanic. 

But  if  we  calculate  these  mentioned  cases  on  the  basis  of 
the  1420  cases,  we  see  that  with  the  older  cases , 2.74  per 
cent,  of  the  relapses  occurred  in  the  character  of  tertiary 
syphilis , a proportion  which,  according  to  the  already  men- 
tioned reasons,  does  not  come  up  to  the  percentage  there 
obtained. 

In  the  following  table  we  see,  excepting  those  cases  of 
serious  disease,  how  the  relapses  are — whether  of  the  char- 
acter of  progressive  or  regressive  syphilis. 

A.  Sarsaparilla  Sweat-cure  (456  Cases). 


Affection  at  relapse. 


1 Eel. 


2 Rel. 


3 Rel. 


4 Rel.  5 Rel. 


> Rel. 


7 Rel. 


Affection  when  first  treated. 


1.  Condylomata  lata  on  the  geni- 
tals (148  cases), 

2.  Throat  affections  (36  cases), 

3.  Exanthema  maculosum  (165 

cases), 

4.  Exanth.  papulosum  (s.  maculo- 
papulosum),  (65  cases), 

5.  Exanthema  squamosum  (s.  pap- 
ulo-squamosum),  (42  cases), 


38  64 

ii  13 


66 


56 


22 


19 


10  14 


27 

7 


4 15 

2 3 


25 


18 


9 10  4 


7 10 


1 

1 


RELAPSES  OF  SYPHILIS. 


225 


B.  Mercury  Cure  (408  Cases). 


Affection  when  first  treated. 


Affection  at  relapse. 


1 Rel.  2 Rel.  3 Rel.  4 Rel.  5 Rel.  6 Rel.  7 Rel 


a a 


c5  a 

gs 

V Q 

a S 

•*-'  i> 

co 


a 

£ a 


1.  Condylomata  lata  on  the  geni- 
tals (296  cases), 

2.  Throat  affection  (9  cases), 

3.  Exanthema  maculosum 


cases), 

4.  Exanthema 
cases), 

5.  Exanthema 
cases), 

6.  Exanthema 
cases), 


papulosum 

squamosum 

pustulosum 


(63 

(14 

(14 

(12 


175 

l 

42 

7 

8 
6 


64 

1 


C.  Subcutaneous  Sublimate  Injection  (800  Cases). 


Affection  at  relapse. 


Affection  when  first  treated. 

Condylomata  lata  on  the  £ 
genitals.  ® 

to 

Throat  affection.  W 

CO 

Exanthema  maculosum.  W 

Exanthema  papulosum  ^ 

(s.  maculo-papulosum). 

Exanthema  squamosum  ^ 
(s.papulo-squamosum). 

Exanthema  pustulo-  ^ 

ulcero-crustosum. 

1. 

Condylomata  lata  on  the  genitals,  . 

11 

2 

3 

2 

2 

2 

2. 

Throat  affection,  .... 

5 

7 

1 

1 

1 

3. 

Exanthema  maculosum,  . 

16 

25 

11 

5 

2 

4. 

Exanthema  papulosum  (s.  maculo- 

papulosum),  ..... 

18 

12 

5 

3 

3 

1 

5. 

Exanthema  squamosum  (s.  papulo- 

squamosum),  ..... 

6 

12 

4 

1 

3 

1 

6. 

Exanthema  pustulo-ulcero-crusto- 

sum,  ...... 

3 

1 

1 

2 

Total,  109  Regressive,  37  Identical,  26  Progressive  forms  of  Relapse. 


226 


RELAPSES  OF  SYPHILIS. 


This  tabular  statement  exhibits  what  syphilitic  affection 
existed  at  the  first  treatment,  and  what  forms  of  relapse 
appeared,  whether  treated  with  the  mercurial,  botanic,  or 
subcutaneous  injection  cure.  The  full-faced  figures  designate 
the  number  of  those  patients  who  had  a relapse  of  the  same 
form  of  syphilis  as  existed  at  the  first  treatment.  The  figures 
on  the  right  side  of  these , show  the  higher  developed , while 
those  on  the  left  show  the  less  developed  forms  of  syphilis  in 
the  relapse. 

In  order  to  compare  the  character  of  the  relapses  after  the 
different  treatments,  I give  the  following : — 


Regressive 

Form. 

Identical 

Form. 

Progressive 

Form. 

I.  Botanic  Treatment, 

47  per  ct. 

21  per  ct. 

32  per  ct. 

68  per  ct. 

II.  Mercurial  Treatment, 

18.6  per  ct. 

46.6  per  ct. 

34.8  per  ct. 

III.  Subcutaneous  Injec- 

65.2 per  ct. 

tion  Cure, 

61.7  per  ct. 

20.9.per  ct. 

17.4  per  ct. 

82.6  per  ct. 

• 

The  result  is  therefore  that  those  relapses , which  occur 
after  the  subcutaneous  sublimate  injection  method , show : — 

17  per  cent,  of  less  progressive  forms 
25  per  cent.  11  11  adequate  u 

43  per  cent.  11  more  regressive  11 


than  the  other  methods  of  treatment  which  have  heretofore 
been  used  in  the  Charite . 

Of  the  patients  with  progressive  relapses  after  the  subcu- 
taneous injections,  none  were  taken  with  a bad  form  of 
tertiary  syphilis. 


RELAPSES  OF  SYPHILIS. 


227 


Only  in  a few  patients,  which  showed  already  before  the 
sublimate  injection  malignant  formations,  did  a malignancy 
appear  in  the  relapse,  and  then  in  a mild  manner. 

Of  the  remaining  patients  of  the  category  of  progressive 
relapses,  not  one  was  really  taken  with  a severe  affection. 
The  following  cases  I show  as  examples : 

1.  Carol  B.,  received  July  9,  1867,  the  first  time  into  the  Charite, 
affected  with  condylomata  lata  at  the  genitals,  angle  of  the  mouth  and 
between  the  fingers  and  toes  ; a light  papulous  exanthem  on  the  thigh. 
She  received  3f  gr.  of  sublimate  hypodermically,  and  was  discharged 
cured. 

She  returned  in  five  and  a half  months  with  the  single  affection, 
condylomata  lata  at  the  entrance  of  the  vaginae,  erosed  considerably. 
There  were  injected  If  gr.  sublimate,  which  dispelled  the  affection.  On 
the  9th  December,  1868,  L e.,  nine  months  subsequently,  she  came  back 
again,  having  the  following,  viz. : ulcerated  condylomata  lata  at  the 
labia,  nates  and  left  thigh  ; great  crusts  at  the  nates , crust-like  formations 
on  the  leg  and  right  fore  arm.  The  inferior  and  superior  extremities  were 
quite  covered  with  a maculous  cicatrized  pigment  colored  eruption  At 
the  posterior  commissura  was  a large  putrid  ulcer.  We  repeated  the 
subcutaneous  injections.  At  the  9th  injection  (1J  gr.  having  been 
used)  so  severe  a salivation  occurred  (lasting  four  weeks)  that  we  sus- 
pended the  injection  treatment  entirely.  We  used  for  two  weeks  iodide 
of  potassium,  and  finally  a sarsaparilla  sweat-cure  for  four  weeks,  and 
thus  we  were  able  to  discharge  the  patient,  after  four  months,  as  cured. 

2.  Auguste,  E.,  was  in  my  wards  from  June  15,  till  July  15,  1867,  for 
ulcerations  in  the  fossa  navicularis  and  erosions.  She  was  treated  with 
sublimate  injections,  receiving  1 gr.  hypodermically.  Four  weeks  later 
she  returned  to  the  Charite  with  crustaceous  erosions  on  the  left  labium 
min.  with  soft  ulcers  on  the  fossae,  and  a papulo-pustulosum  exanthema 
on  the  back,  abdomen,  and  lower  extremities.  After  injecting  lj-  gr.  of 
sublimate  subcutaneously,  the  exanthem  disappeared. 

3.  Anna  H.,  was  received  November  12,  1866,  for  lata  at  the  genitals 
and  fossa,  erosion  on  the  nose,  psoriasis  palmaris,  rhagades  between 
the  toes  of  the  left  foot  and  a pustulous  exanthem  about  the  head.  She 
received  2 gr.  of  sublimate  subcutaneously,  and  the  exantliem  disap- 
peared, pigment  patches  only  remaining. 


228 


KELAPSES  OP  SYPHILIS. 


On  account  of  a primary  affection,  she  returned  five  times  to  the  hos- 
pital, and  returned  once  again  January  23,  1869,  i.  e.,  two  years  and 
three  months  after  her  first  discharge,  this  time  having  crustaceous 
ulcerations,  ecthymatous  eruption  on  the  lower  extremities,  crusts  on 
the  nates.  She  received  subcutaneously  J gr.  of  sublimate.  A stoma- 
titis mercuriales  ensued,  and  she  was  then  treated  with  a sarsaparilla 
sweat-cure,  and  received  thereafter  \ gr.  of  sublimate  more,  and  was 
discharged  cured. 

4.  Mrs,  Kl.,  twenty-one  years  old,  already  four  times  treated  for 
primary  syphilitic  processes,  was  again  received  into  the  hospital  Oc- 
tober 3,  1866,  with  condylomata  lata  near  the  anus  and  on  the  tonsil, 
maculous  exanthem,  loss  of  hair  and  adenitis.  She  was  treated  subcu- 
taneously, and  was  discharged  cured  after  using  2f  grs.  of  sublimate. 
She  returned  again,  after  four  and  a half  months,  to  the  Charite,  with 
eroded  tonsils  and  three  pustules,  of  the  size  of  a pea,  on  the  left  fore- 
arm. They  dried  up,  after  the  use  of  f gr.  of  sublimate,  hypodermi- 
cally. When  If  gr.  had  been  used,  the  crust  fell  off,  and  the  patient 
was  discharged  cured.  Subsequently  she  returned  to  my  wards  several 
times,  but  I could  not  detect  anything  of  these  syphilitic  formations. 

5.  Emilie  Sch.,  twenty-one  years  old,  received  into  my  wards  Feb- 
ruary 24,  1867,  with  indurated  ulcers  on  the  right  of  the  labia 
minora,  condylomata  lata  on  the  tonsils,  papulous  exanthem  over  the 
whole  body  ; was  discharged  cured  after  the  injection  of  1-g-  gr.  of  sub- 
limate. She  returned  in  the  course  of  a month,  and  we  found  eight 
crusts,  of  the  size  of  a pea,  of  yellow  color,  resembling  impetigo,  seated 
on  a superficially  eroded  cuticle  upon  the  neck  and  abdomen.  After 
the  hypodermic  injection  of  If  gr.  of  sublimate,  we  discharged  her 
cured,  and  when  last  heard  from  she  remained  perfectly  well. 

6.  Augusta  L.,  eighteen  years  old,  received  into  the  Charite  April 
18,  1866,  with  condylomata  lata  on  the  genitals  and  maculous  exan- 
them ; was  treated  for  six  or  seven  weeks  with  the  sarsaparilla  sweat- 
cure.  During  the  while,  papules  developed  themselves  on  the  back. 
An  injection  treatment  was  instituted,  which  resulted,  after  using  3 grs. 
of  sublimate,  in  a cure.  After  six  weeks,  the  patient  returned  with  the 
following  symptoms : eroded  condylomata  on  the  left  arcum  palato- 
pharyngeum,  impetiginous  exanthem  on  the  lower  extremities,  psoriasis 
palmaris  and  adenitis.  This  time  the  use  of  2 grs.  was  sufficient.  But 
the  patient  came  back  again,  three  months  subsequently,  with  an  ulcer 
on  the  lower  eyelid,  which  had  caused  some  loss  of  substance.  Also, 


RELAPSES  OF  SYPHILIS. 


229 


the  epiglottis  exhibited  superficial  erosions.  All  of  these  processes  did 
not  appear  to  me  evidently  of  a syphilitic  character,  and  I prescribed 
iodide  of  potassium.  After  the  use  of  gii,  a healing  was  effected. 

7.  Fred.  H.,  eighteen  years  old,  received  into  my  wards  January  27tli, 
1867,  with  eroded  condylomata  on  the  left  of  the  labia  minora  and 
urethritis;  was  discharged  cured  after  the  use  of  % gr,  of  sublimate. 
After  the  lapse  of  three  months,  he  returned  to  the  hospital,  with  a 
papulous  exanthem  on  the  face  and  extremities.  We  used  again  the 
subcutaneous  sublimate  injection  cure,  5 grs.  completing  the  cure. 

Among  the  remaining  cases  in  which  a progress  of  syphilis 
was  stated,  in  twelve  cases  the  most  significant  affection  was 
a papulous  exanthema,  and  in  six  cases  a squamous  exan- 
thema. Subcutaneous  injections  of  sublimate,  to  the  amount 
of  from  1 gr.  to  2|  grs.,  always  brought  these  syphilitic 
processes  to  a stand-still. 

In  the  remaining  progressive  relapses,  after  broad  condy- 
lomes  on  the  genitals  or  superficial  erosions  in  the  pharynx, 
a maculous  exanthem  was  the  result. 

It  is  of  importance  that,  for  the  cure  of  the  relapses  gen- 
erally , only  from  half  to  three-fourths  the  quantity  of  subli- 
mate is  necessary  to  eradicate  the  first  eruptions  of  syphilis, 
as  is  shown  by  the  following  tabular  statement  : 


23 


230 


RELAPSES  OF  SYPHILIS. 


P 

m 

Ph 

H 

p 

w 

Ph 

P 

H 

P 

<J 

W 

H 

<1 

a 

►h 

H 

W 

P 


P 

o 


oa 

O 

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RELAPSES  OF  SYPHILIS. 


231 


Concerning  the  question  ivhether  a too  small  quantity  of 
injected  sublimate  may  cause  the  appearance  of  relapses , it 
is  very  difficult  to  answer,  since  we  saw  no  deviation,  the 
quantity  for  relapses  being  a trifle  less  than  for  other 
cases.  With  several  relapses  the  average  quantity  of  the 
injected  sublimate  is  less  than  when  but  a single  relapse 
occurs,  as  shown.  That  my  figures  concerning  quantity  and 
quality  of  relapses  after  subcutaneous  injections  have  not 
been  taken  too  favorably,  can  be  seen  from  the  following 
statement  of  the  present  status  of  my  wards  for  syphilis . 

Number  of  prostitutes  subcutaneously  treated  during  the  years  from 
1865  to  1869,  between  .......  1300  and  1400 

Number  of  relapsing  women  in  my  wards,*  . . . . .20 


And  they  suffered  as  follows  : — 


From  condylomata  lata  on  the  genitals  or  surroundings, 

11  11  11  and  erosions  on  the  tonsils, 

11  11  11  11  and  exanthema  maculosum, 


Exanthema  papulosum, 

“ papulo-squamosum,  ..... 
u 11  11  and  ulceration  on  tonsils, 


u 

u 

u 


crustosum, 

u 

u 


and  periostitis, 
u retinitis, 


10 

2 

2 

1 

1 

1 

1 

1 

1 


* I point  out  here  again  that  my  wards  probably  represent  the  full 
contingency  of  all  syphilitic  women  in  Berlin,  and  for  that  reason  give 
a fair  estimate  of  all  the  relapses  after  the  sublimate  injection  cure. 
Not  only  are  the  prostitutes  examined  weekly  by  proper  sanitary  in- 
spectors, but  also  they  are  sent  immediately  to  my  wards.  No  other 
hospital  is  allowed  to  receive  persons  so  diseased.  Only  a few  of  the 
better  situated  puellae  publicae  have  been  allowed  to  be  treated  in  their 
homes,  but  these  have  not  been  subcutaneously  treated  by  me.  Con- 
cerning the  other  wards  of  the  Charite,  in  which  sometimes  women 
with  visceral  syphilis  are  found,  only  one  patient  in  the  insane  ward  ot 
Professor  Westphal  has  been  treated  subcutaneously.  Diagnosis  here 
is  not  quite  certain,  but  it  seems  that  a hemiplegia  induced  by  syphilis 
exists  with  the  patient. 


232 


RELAPSES  OF  SYPHILIS. 


INTERVALS  BETWEEN  THE  SINGLE  RELAPSES. 

It  would  be  advantageous  if  we  could  use  the  intervals  of 
the  single  relapses  as  a prognostic  mean  in  reference  to  the 
further  course  of  the  syphilis.  All  the  views  and  assertions 
of  former  syphilographs  are  lacking  a reliable  statistical 
basis,  and  are  therefore  only  subjective  in  their  origin. 
Hence  the  contradictions  of  the  authors.  For  instance , 
Von  Bcerensprung  regards  longer  intervals , especially  after 
mercury , as  a less  favorable  prognostic  significance . Diday 
reverses  the  matter , and  regards  short  intervals  as  unfavorable 
in  a prognostic  point  of  view . 

In  my  work  in  the  Charite  Annals,  I have  pointed  out 
the  non-correspondence  of  the  views  of  Yon  Baerensprung 
with  the  result  of  his  own  records  in  his  “ Sick  Journal, 99 
besides  showing  the  insufficiency  of  the  material  of  Diday. 
The  observations  of  the  39  cases  of  tertiary  syphilis  which 
are  found  in  the  records  of  my  predecessors,  induced  me  to 
think  that  the  character  of  the  relapsing  syphilis  does  not 
depend  on  the  intervals  between  the  outbreaks. 

As  to  the  intervals  in  which  the  simple  relapsing  affections 
occurred  in  the  patients  of  my  predecessors,  and  as  to  the 
intervals  occurring  after  my  subcutaneous  injection  cure,  I 
have  taken  of  the  former  912  patients,  observing  them  more 
minutely,  and  of  the  latter  800.  When  compared,  the 
result  is  as  follows  : — 

A.  Sarsaparilla  Sweat-Cure.  456  Cases. 

At  the  first  treatment  were  : 

I.  Condylomata  lata  on  the  genitals,  ...  in  148  cases. 

Relapses  occurred  as : 

Condylomata  lata  on  the  genitals  . . . “ 38  “ 


INTERVALS  BETWEEN  THE  SINGLE  RELAPSES.  233 


Condylomatous  erosions  and  ulcerations  in  the 

pharynx 

Exanthema  maculosum 

during  5 months  . 

“ 11  “ 

Exanthema  papulo-squamosum 

during  5 months  . 

“ 11  “ 

II.  Condylomatous  erosions  and  ulcerations  in  the 

pharynx 

Relapses  occurred  as : 

Condylomata  lata  on  the  genitals 
Condylomatous  erosions  and  ulcerations  in  the 

pharynx 

Exanthema  maculosum 

They  were  divided  as  follows,  occurring  during  6 mos. 
Exanthema  papulo-squamosum  . 

III.  Exanthema  maculosum  with  or  without  affec- 

tions of  the  Category  I.  and  II. 

Relapses  occurred  as : 

Condylomata  lata  on  the  genitals 
They  were  divided  as  follows : during  9 months  . 

“ 28  “ 

Condylomatous  erosions  and  ulcerations  in  the 

pharynx 

They  were  divided  as  follows : during  8 months  . 

“ 24  “ 

Exanthema  maculosum 

during  7 months. 
Exanthema  papulo-squamosum  . 

during  8 months. 

IV.  Exanthema  papulosum  with  or  without  the  affec- 

tions of  Category  I.  to  III 

Relapses 'occurred  as : 

Condylomata  lata  on  the  genitals 

during  11  months  . 

Condylomatous  erosions  and  ulcerations  in  the 
pharynx  during  10  months  . 

Exanthema  maculosum 

during  11  months  . 

20* 


in  64  cases. 
u 27  “ 

“ 25  u 

a 2 “ 

“ 15  “ 

“ 13  “ 

u 2 “ 

“ 12  “ 

“ 11  “ 

“ 13  “ 

u 12  “ 

u 5 “ 

“ 165  “ 

“ 66  “ 

“ 59  “ 

u y a 

“ 56  “ 

“ 50  “ 

U 6 (4 

“ 25  “ 

a 18  a 


“ 165  « 


a 22  11 

a 19  a 

a 9 a 


234 


RELAPSES  OF  SYPHILIS. 


Exanthema  papulosum 

during  12  months  . 
Exanthema  papulo-squamosum 

during  4 months  . 

Exanthema  pustulosum 

during  2 months  . 

Y.  Exanthema  squamosum  with  or  without  the  affec- 
tion of  Category  I.  to  IY.  . 

Relapses  occurred  as  : 

Condylomata  lata  on  the  genitals 

during  5 months  . 

Condylomatous  erosions  and  ulcerations  in  the 
pharynx  during  5 months  . 

Exanthema  maculosum 

during  12  months  . 
Exanthema  papulo-squamosum 

during  13  months  . 

Exanthema  vesiculosum 

during  18  months . 


in  10  cases 
u 4 u 

u i u 

“ 32  “ 


“ 10  “ 

“ 14  a 

U >J  li 

u 10  « 

<•  l « 


B.  Mercury  Cure.  456  Cases. 


4.t  the  first  treatment  were  : 

I.  Condylomata  lata  on  the  genitals 
Relapses  occurred  as : 

Condylomata  lata  on  the  genitals 

Condylomatous  erosions  and  ulcerations  in  the 
pharynx  ........ 

Exanthema  maculosum 

during  9 months  . 

“ 48  “ 

Exanthema  papulosum 

during  9 months  . 

“ 30  “ 

Exanthema  squamosum 

during  4 months  . 

“ 14  “ 

Exanthema  pustulosum  ..... 

during  7 months. 


“ 296  « 

“ 175  “ 

« 64  “ 

“ 30  “ 

u 24  “ 

a 6 11 

u 13  “ 

u 9 u 

u 4 u 

u 6 a 

“ 5 “ 

U l u 

“ 6 “ 


INTERVAL  BETWEEN  THE  SINGLE  RELAPSES. 


235 


II.  Condylomatous  erosions  and  ulcerations  in 
. pharynx  ....... 

the 

in 

93  cases. 

Relapses  occurred  as : 

Condylomata  lata  on  the  genitals 

it 

1 

tl 

Condylomatous  erosions  and  ulcerations  in 
pharynx  ....... 

the 

it 

1 

it 

Exanthema  maculosum  .... 

tt 

5 

tl 

during  6 months  . 

tt 

3 

It 

“ 18  “ 

tt 

2 

It 

Exanthema  papulo-squamosum  . 

it 

1 

It 

during  7 months. 

Exanthema  pustulosum  .... 

it 

1 

it 

during  3 months. 

III.  Exanthemata  maculosum  with  or  without 
affections  of  Category  I.  and  II. 

the 

it 

63 

tl 

Relapses  occurred  as  : 

Condylomata  lata  on  the  genitals 

a 

42 

It 

during  9 months  . 

. 

it 

37 

a 

“ 36  “ 

It 

7 

tt 

Condylomatous  erosions  and  ulcerations  in 
pharynx  ....... 

the 

it 

8 

tt 

during  6 months. 

Exanthema  maculosum  .... 

It 

5 

tt 

during  8 months  . 

It 

4 

it 

“ 13  “ 

. 

It 

1 

it 

Exanthema  papulosum  . 

It 

3 

tt 

during  6 months. 

Exanthema  pustalosum  . . . 

It 

2 

it 

during  11  months. 

Exanthema  tuberculosum  .... 

. 

it 

3 

tt 

during  36  months. 

'IV.  Exanthema  papulosum  with  or  without 
affection  of  Category  I.  to  III. 

the 

(l 

14 

it 

Relapses  occurred  as  : 

Condylomata  lata  on  the  genitals 

It 

7 

a 

during  10  months  . 

It 

4 

it 

“ 17  “ 

tl 

1 

tt 

Exanthema  papulosum  .... 

. 

It 

o 

it 

during  10  months. 


236 


RELAPSES  IN  SYPHILIS. 


Exanthema  vesiculo-pustulosum  ...  in  4 cases, 

during  10  months. 

Y.  Exanthema  squamosum  with  or  without  the 
affection  of  Category  I.  to  IV. 

Relapses  occurred  as  : 

Condylomata  lata  on  the  genitals  ...  u 8 “ 

during  13  months. 

Erosions  and  ulcerations  in  the  pharynx  . . “ 1 “ 

during  3 months. 

Exanthema  maculosum u 2 11 

during  19  months. 

Exanthema  papulosum  .....  a 1 a 

during  1 month. 

Exanthema  squamosum “ 2 11 

during  4 months. 

YI.  Exanthema  pustulosum  with  or  without  the 

affections  of  Category  I.  to  Y.  . . . “ 12  “ 

Relapses  occurred  as  : 

Condylamata  lata  on  the  genitals  . . . 11  6 “ 

during  20  months. 

Exanthema  pustulosum “ 4 “ 

during  24  months. 

Exanthema  luposum 11  2 “ 

during  10  months. 


C.  Subcutaneous-Injection-Cure.  182  Cases. 
At  the  first  treatment  were  : 

I.  Condylomata  lata  on  the  genitals  and  surround- 


ings  “ 22  “ 

Relapses  occurred  as  : 

Condylomata  lata  on  the  genitals  ...  11  10  11 

during  8 months. 

Erosions  and  ulcerations  in  the  pharynx  . . 11  3 u 

during  2 months. 

Exanthema  maculosum u 3 u 

during  4 months. 

Exanthema  papulo-squamosum  ....  11  4 11 

during  4 months. 

Exanthema  pustulosum “ 2 “ 

during  3 months. 


INTERVAL  BETWEEN  THE  SINGLE  RELAPSES. 


237 


II.  Erosions  and  ulcerations  in  the  pharynx  with  or 
without  the  affections  of  Category  I. 

in 

14  cases 

Relapses  occurred  as  : 

Condylomata  lata  on  the  genitals 

ll 

5 

u 

during  5 months. 

Erosions  and  ulcerations  in  the  pharynx  . 

it 

1 

ii 

during  6 months. 

Exanthema  maculosum 

Cl 

1 

ii 

during  3 months. 

Exanthema  papulosum 

u 

1 

ii 

during  14  months. 

Exanthema  squamosum  ..... 

Cl 

1 

ii 

during  7 months. 

III.  Exanthema  maculosum  with  or  without  the 
affections  of  Category  I.  to  II.  ... 

ll 

55 

ii 

Relapses  occurred  as  : 

Condylomata  lata  on  the  genitals 

Cl 

15 

ii 

during  12  months. 
Erosions  and  ulcerations  in  the  pharynx  . 

u 

23 

ii 

during  9 months. 

Exanthem  maculosum  ..... 

ll 

10 

ii 

during  9 months. 

Exanthema  papulosum  ..... 

ll 

5 

i 

during  8 months. 

Exanthema  squamosum 

ll 

2 

ii 

during  4 months. 

IY.  Exanthema  papulosum  with  or  without  the 
affections  of  Category  I.  to  III. 

It 

41 

ii 

Relapses  occurred  as  : 

Condylomata  lata  on  the  genitals 

ll 

16 

ii 

during  17  months. 

, Erosions  and  ulcerations  in  the  pharynx  . 

It 

13 

it 

during  11  months. 

Exanthema  maculosum  ..... 

ll 

5 

ti 

during  21  months. 

Exanthema  papulosum 

ll 

3 

ii 

during  15  months. 

Exanthema  squamosum 

It 

3 

u 

during  2 months. 

238 


RELAPSES  IN  SYPHILIS. 


Exanthema  pustulosum 

during  16  months. 

Y.  Exanthema  squamosum  with  or  without  the 

in 

1 cases. 

affections  of  Category  I.  to  IY. 

Relapses  occurred  as: 

u 

30 

ii 

Condylomata  lata  on  the  genitals 

during  10  months. 

ll 

8 

u 

Erosions  and  ulcerations  in  the  pharynx  . 

during  13  months. 

it 

13 

ii 

Exanthema  maculosum 

during  9 months. 

ti 

3 

it 

Exanthema  papillosum 

during  7 months. 

it 

2 

u 

Exanthema  squamosum 

during  7 months. 

it 

3 

u 

Exanthema  pustulosum 

during  6 months. 

VI.  Exanthema  pustulosum  with  or  without  the 

ll 

1 

u 

affections  of  Category  I.  to  Y. 

Relapses  occurred  as  : 

ti 

10 

u 

Condylomata  lata  on  the  genitals 

during  8 months. 

ll 

1 

n 

Erosions  and  ulcerations  in  the  pharynx  . 

during  8 months. 

ti 

3 

u 

Exanthema  maculosum 

during  2 months. 

a 

1 

u 

Exanthema  papulosum 

during  8 months. 

u 

3 

u 

Exanthema  pustulosum  ..... 

during  15  months. 

u 

2 

it 

Following  are  two  tabulated  statements,  of  which  the  first 
shows,  how  many  relapses  those  patients  had,  who  were  sub- 
cutaneously treated ; in  the  second  it  shows  the  difference 
in  intervals  with  such  patients,  who  have  undergone  one  or 
more  relapses . 


RELAPSES  OF  SYPHILIS. 


239 


Manifold  Relapses. 


Categories. 

1st  Relapse. 

2d  Relapse. 

3d  Relapse. 

4th  Relapso. 

5th  Relapso. 

I.  (41  cases) 
II.  (21  “ ) 

IH.a  (7  “ ) 

111.6(26  “ ) 
III.c  (53  “ ) 

III .d  (9  “ ) 

IY.a  (10  “ ) 

IY.6  (5  “ ) 

in  1 9 cases. 
“ 11  “ 

“ 3 “ 

“ ^ ci 

“ 26  “ 

“ 3 “ 

u 7 U 

u 3 It 

in  12  cases. 

“ 8 “ 

u 2 11 

u y a 

u 15  II 

u 4 it 

u ^ 11 

u 2 11 

in  10  cases. 

it  2 11 

it  2 u 

u 2 

“11  “ 

« 2 u 

it  2 tl 

it  it 

in  1 case.- 

n 2 tt 

in  1 case. 

a 2 it 

Total 

in  89  cases. 

in  50  cases. 

in  29  cases. 

in  2 cases. 

in  2 cases. 

This  statement  shows,  besides  the  important  fact,  that  in 
the  greatest  number  of  patients  only  one  or  two  relapses 
occur ; three  relapses  are  rare,  but  four  and  five  the  excep- 
tions. To  show  the  intervals  of  manifold  relapses,  the 
following  table  is  inserted. 


240 


RELAPSES  OF  SYPHILIS, 


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SUBCUTANEOUS  INJECTIONS  IN  PREGNANCY.  241 


As  seen  by  this  table  the  intervals  are  longer  with  those 
patients  in  whom  but  one  relapse  occurred,  and  shorter  in 
those  in  whom  several  relapses  followed. 


IX.  EFFECT  OF  SUBCUTANEOUS  INJECTIONS  IN 
PREGNANCY. 

Dr.  Jul,  Loewy  publishes  from  Siegmund’s  Clinic  at 
Vienna  some  very  valuable  points  thereon.  From  January, 
1868,  till  April,  1869,  99  syphilitic  pregnant  females  were 
treated:  58  expectantly,  37  with  inunction. 

With  the  .58  pregnant  females  of  the  first  class,  abortion 
or  premature  delivery  occurred  17  times,  or  29  per  cent. ; 
with  the  37  of  the  second  class,  abortion  or  premature  deli- 
very 5 times,  or  13.5  per  cent. 

The  number  of  syphilitic  pregnant  females  treated  by  me 
subcutaneously  since  1865,  up  to  April,  1869,  were  85.  In 
this  number  abortion  or  premature  birth  occurred  but  8 
times,  or  with  about  10  per  cent.  The  result  therefore  is, 
that  with  the  subcutaneous  sublimate  treatment,  abortion 
and  premature  delivery  took  place  19  per  cent,  less  fre- 
quently than  with  the  expectant  treatment,  and  3 per  cent, 
less  frequently  than  with  the  inunction  cure. 

I do  not  put  much  value  on  this  latter  circumstance  of  3 
per  cent,  for  my  method,  since  changeable  factors  might 
have  caused  the  variation. 

Tbe  85  pregnant  females  were  in  all  stages  of  gestation 
during  the  hypodermic  treatment,  as  here  seen: 


21 


242  SUBCUTANEOUS  INJECTIONS  IN  PKEGNANCY. 


In 

the  3d  or  4th  lunar 

month 

. 13 

u 

u 

5th 

ll 

u 

7 

a 

Cl 

6 th 

Cl 

ii 

. 12 

u 

u 

7 th 

It 

u 

18 

n 

u 

8th 

u 

ll 

. 17 

a 

u 

9th 

u 

ll  . 

8 

u 

u 

10  th 

i: 

ll 

. 10 

Accordingly  we  perceive  that 

20  were  in  the  first  half  of  gestation. 
65  “ “ “ second  “ “ 


Abortion  or  premature  birth  occurred  respectively, 


In  the  3d  lunar  month  with  1 person. 
u u 4th  u u u 2 u 

“ “ 5th  « “ “ 1 « 

“ 7th  “ “ “ 1 - 

“ “ 8th  “ “ “ 2 “ 

u u 9th  tt  « “ 1 “ 


Here  we  see  that  women  in  the  earlier  months  of  preg- 
nancy, who  are  more  disposed  to  abort,  bore  the  subcutaneous 
injections  of  sublimate  without  any  bad  result. 

Concerning  the  second  important  question,  as  to  hoiv 
gestation  proceeded  after  the  injection  treatment , I cannot 
give  so  large  a statistical  exhibit,  because  a part  of  the 
patients  left  our  hospital  before  confinement,  and  therefore 
did  not,  come  under  my  observation. 

Of  50  patients  I can  make  the  following  statement : 

16  women  were,  from  1 to  1J  months  after  the  treatment, 
delivered,  in  their  7th  or  8th  months  of  pregnancy. 

14  women  were,  from  1 to  2|  months  after  the  treatment, 
delivered,  in  their  8th  or  9th  months  of  pregnancy. 

20  women  were  delivered  at  full  term. 


SUBCUTANEOUS  INJECTIONS  IN  PREGNANCY.  243 

Concerning  the  influence  of  our  cure  on  the  life  and 
health  of  the  foetus , 

43  pregnant  females  gave  birth  to  32  living  and  11  dead 
children. 

Of  the  32  living  children,  20  children,  or  62J  per  cent, 
died. 

The  remaining  12  were  discharged  with  the  mother,  and 
for  only  2 children  was  an  inunction  cure  thought  necessary. 

Of  these  12  children,  discharged  seemingly  healthy,  I 
have  been  able  to  ascertain  nothing  of  but  5 : 2 died ; 3 are 
yet  alive  and  well. 

Of  9 children  who  died  in  the  Charity,  a post-mortem 
examination  showed  the  existence  of 

Encephalitis I.  ...  2 times. 

u with  Hepatitis 1 “ 

Peritonitis  with  Hepatitis  and  Atelectasia  Pulmonum  . . 1 “ 

Ostitis  gummosa  multiplex,  Rhachitis,  Thrombophlebitis  . 1 11 

Ostitis  gummosa  multiplex,  Hepatitis  gummosa,  Broncho- 
pneumonia   1 “ 

Ostitis  gummosa  multiplex,  Hepatitis  gummosa,  Pemphigus, 

Abcessus  glandulae  Thymus 1 11 

Atrophia  universalis,  Exanthema  squamosum  Furunculosis  . I “ 


V 


INDEX. 


PAGE 

Abscesses,  formation  of  . 21 

Acute  diseases 203 

Age 202 

Alopecia,  mercurial  33 

Appearances  of  places  injected 20 

Blood,  formation — disturbances  of  .....  33 

Bones,  syphilitic  affection  of 175 

therapeutics  of  ........  17G 

Cases  62-64  177-180 

Brain,  syphilitic  affection  of 191 

therapeutical  indications  .......  193 

Cases  69-71  196-201 

Bubos,  ulcerated 61 

Circulation,  disturbances  of 32 

Combination  cures,  most  desirable 209 

Condylomata  lata 47 

seat  of  (in  women) 51 

with  other  exanthemata  . . . 53 

seat  of  (in  men) 54 

with  other  exanthemata  . . . 55 

therapeutics  of 56 

verrucosa 60 

mixta  .........  60 

local  treatment  of 60-63 

Condylomatous  exanthema 144 

its  frequency 145 

treatment 145 

Cases  46-47  ....  146-149 

Condylomes  in  larynx , 108 

21* 


246 


INDEX, 


PAGE 

Definition  ..........  14 

Depres 217 

Desruelles 212 

Devergie 211 

Diday  ...........  214 

Dietetic  rules  . . . 39 

Digestion,  disturbances  of  . 25 

Doses,  generally  used  . . . 19 

after  relapses 230 

Dyscrasia 203 

Engelsted 215 

Eye,  syphilitic  affections  of  . 164 

complications  with  other  affections 166 

iritic  inflammation  of 167 

Cases  55-60  167-171 

Fergusson 212 

Fovae  tonsillares 73 

Glands,  lymphatic 63 

mucous 69 

Glandulae  acinosae . . . 69 

Gummata  of  subcutaneous  tissue 159 

Cases  53,  54  . . . 161-164 

Gummy  tumors,  knots 82 

Case  12  90 

Hermann 213 

Icterus,  syphiliticus 182 

with  other  syphilitic  affections 183 

effect  of  sublimate  injections  on 183 

Cases  65,  66  184-185 

Idiosyncrasy  of  patients  . . . 0 24 

Infectio  per  os 95 

diagnosis  of 100 

Cases  19-26  98-102 


INDEX. 


247 


PAGE 

Infection  of  nurse  via  child,  &c 102 

Case  27 103 

Infiltration,  submucous 106 

gummous  ........  128 

Injection,  place  for 15 

mouth  affections  from 26 

strengths  of 17 

inflammation  from 20 

general  symptoms  after  .......  25 

abscesses  from  21 

indications  for  43 

respiratory  disturbance  from 32 

considerations  respecting  ......  202 

interruption  of  sensibility  from  ....  223 

effect  in  pregnancy 229 

on  foetus 243 

Intoxication  from  sublimate 37 

Iritis,  syphilitic  . 167 

Kidney,  syphilitic  affection  of  . . . . . . 186 

Cases  67,  68  . . . 188-19,1 

Knots,  gummous,  in  scrotum 174 

Knotty  syphiloid . . 151 

Larynx,  syphilitic  affections  of  . . . . . . .104 

catarrh  of 104 

stenosis  of . . 106 

condylomatous  granulations  in 107 

inflammation  of 110 

therapeutics  of 116 

Cases  28-40  . . . . . . . . 118-130 

Liver,  syphilitic  diseases  of 181 

Lupus  syphiliticus 152 

Cases  51,  52  155-157 

m 

Maculous  syphiloid 132 

effect  of  sublimate  treatment  on  . . 133 

Manner  of  using 14 

Menstruation 202 


248 


INDEX. 


PAGE 

Mercurial  eczema 33 

Mercury,  physical  effect  of . . . 36 

Mouth  effects,  syphilitic 66 

Nervous  system,  disturbances  of 35 

(Edema  of  labia  majora 59 

Oewre,  A 217 

Osseous  system,  disturbances  of 33 

Papulous  exanthema 135 

miliary  species  ......  135 

lenticular  species 136 

therapeutics  of 136 

Cases  41-43  137-140 

Pavement  epithelium 108 

Pharynx,  syphilitic  affection  of 66 

therapeutics  of  ........  87 

Cases  1,  2 . . . 70-72 

Cases  9-11 88-90 

Playnes  opalines 72 

Pregnancy  . ...  202 

Prophalaxis  of  mercurialism 28 

Psoriasis  oris 73 

Psychical  considerations  ........  42 

Ptyalism  proper 27 

Relapses  of  syphilis 210 

percentage  of 216 

Table  of  (vide)  ........  221 

intervals  between 221 

after  hypodermic  injections 222 

sarsaparilla  sweat-cure 224 

mercury  cure 225 

subcutaneous  cure  .......  225 

Cases  of  . • . . . . . . . . 227-229 

Rheumatism,  diminished  by  injection 88 

acute  articular 203 


INDEX. 


249 


PAGE 

Scrofulosa,  diagnosis  of,  from  tertiary  ulcers  . . . .115 

Sex 202 

Skin  affection,  syphilitic 131 

Spray  atomization 61 

Squamous  exanthema  . 140 

treatment  of 141 

Cases  44,  45  142-144 

Statistics  of  800  patients  ........  207 

Syphilis,  spontaneous  cure  of 46 

initial 44 

progressive  and  regressive 222 

visceral 180 

Teeth,  care  of 20 

Tonsils,  hypertrophy  of 31 

Cases  72,  73  204-205 

ulcerated 75 

Cases  3-8 76-81 

Tuberculosis,  &c. 204 

Tuberculous  ulcers  diagnosed 116 

Tumors  of  scrotum 171 

therapeutics  of  . . . . . .172 

Case  61  (gummous  knots)  ....  174 

Ulceration  of  false  vocal  cords Ill 

petrolus Ill 

epiglottis Ill 

vocal  cords 115 

Ulcerous  exanthema  and  rupia 147 

Cases  48-50  . . . 148-150 

Urinary  organs,  disturbances  of 32 

Yelum,  ulcerative  processes  of 85 

Vessels,  injury  to  . 22 

Warts,  slender 48 

Yvaren 214 

Zettman’s  decoction 46 


